Provider Demographics
NPI:1083430219
Name:MOORE, ENGRA DE'ETE (BA, MS)
Entity type:Individual
Prefix:
First Name:ENGRA
Middle Name:DE'ETE
Last Name:MOORE
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:GA
Mailing Address - Zip Code:31714-5829
Mailing Address - Country:US
Mailing Address - Phone:229-508-9551
Mailing Address - Fax:
Practice Address - Street 1:521 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:GA
Practice Address - Zip Code:31714-5829
Practice Address - Country:US
Practice Address - Phone:229-508-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor