Provider Demographics
NPI:1902540446
Name:MOORE, LATISHA MONIQUE
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:MONIQUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10584 STEEPLECHASE DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4279
Mailing Address - Country:US
Mailing Address - Phone:228-297-3720
Mailing Address - Fax:
Practice Address - Street 1:10584 STEEPLECHASE DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4279
Practice Address - Country:US
Practice Address - Phone:228-297-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program