MEDICARE: AMY MOORE RD, LD, CDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1004X	Pediatric Nutrition Registered Dietitian	1287	OK

General Provider Information

NPI Number	:	1801010095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY MOORE RD, LD, CDE

Provider Business Mailing Address
First Line	:	PO BOX 30589
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73140-3589
Country	:	US
Telephone Number	:	405-769-3301
Fax Number	:

Provider Business Practice Location Address
First Line	:	12716 N.E. 36TH STREET
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73140
Country	:	US
Telephone Number	:	405-769-3301
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	03/17/2018

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