MEDICARE: HOLLY DAWN MOORE RN

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	163WG0000X	General Practice Registered Nurse	108215	WV

General Provider Information

NPI Number	:	1992560940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY DAWN MOORE RN

Provider Business Mailing Address
First Line	:	2417 MCKIM CREEK RD
Second Line	:
City	:	PENNSBORO
State	:	WV
Zip	:	26415-8026
Country	:	US
Telephone Number	:	304-771-7458
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 LAFAYETTE ST STE 202
Second Line	:
City	:	SAINT MARYS
State	:	WV
Zip	:	26170-1059
Country	:	US
Telephone Number	:	304-684-2656
Fax Number	:

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

Provider Enumeration Date	:	02/19/2024
Last Update Date	:	02/19/2024

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Directions to “ HOLLY DAWN MOORE RN” Practice Location

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