Provider Demographics
NPI:1902668437
Name:MOORE, TIANNA R
Entity Type:Individual
Prefix:
First Name:TIANNA
Middle Name:R
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 1:411 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-8368
Mailing Address - Country:US
Mailing Address - Phone:215-397-5955
Mailing Address - Fax:
Practice Address - Street 1:2839 W GIRARD AVE FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1214
Practice Address - Country:US
Practice Address - Phone:215-397-5955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2167500172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver