Provider Demographics
NPI:1548481682
Name:MOORE, STEPHANIE (LMP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 COBB PKWY N APT 6204
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-9205
Mailing Address - Country:US
Mailing Address - Phone:206-930-4200
Mailing Address - Fax:206-760-0266
Practice Address - Street 1:5150 STILESBORO RD NW STE 430
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7759
Practice Address - Country:US
Practice Address - Phone:470-746-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010605174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty