Provider Demographics
NPI:1730420688
Name:MOORE, STEPHANIE ALICE (RD)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ALICE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 EAST DERENNE AVENUE
Mailing Address - Street 2:ATTN - MARC NETTLES
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:340 EISENHOWER DRIVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-443-4200
Practice Address - Fax:912-355-8124
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL0002834133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered