MEDICARE: MRS. MICHELLE LEJAY MOORE

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	172V00000X	Community Health Worker	01596	TX

General Provider Information

NPI Number	:	1992112361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE LEJAY MOORE

Provider Business Mailing Address
First Line	:	209 E MOORE AVE
Second Line	:
City	:	TERRELL
State	:	TX
Zip	:	75160-3207
Country	:	US
Telephone Number	:	972-551-0038
Fax Number	:	972-551-1821

Provider Business Practice Location Address
First Line	:	209 E MOORE AVE
Second Line	:
City	:	TERRELL
State	:	TX
Zip	:	75160-3207
Country	:	US
Telephone Number	:	972-551-0038
Fax Number	:	972-551-1821

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

Provider Enumeration Date	:	07/17/2014
Last Update Date	:	07/17/2014

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