Provider Demographics
NPI:1063260255
Name:MOORE, DANIELLE IMANI
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:IMANI
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 1:1417 GATES CIR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-4096
Mailing Address - Country:US
Mailing Address - Phone:443-750-8585
Mailing Address - Fax:
Practice Address - Street 1:1417 GATES CIR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-4096
Practice Address - Country:US
Practice Address - Phone:443-750-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program