Provider Demographics
NPI:1104496280
Name:MOORE, ALEXANDRIA NINA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:NINA
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 1:3845 SOUTHRIDGE CIR APT 10
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7955
Mailing Address - Country:US
Mailing Address - Phone:561-901-1043
Mailing Address - Fax:
Practice Address - Street 1:716 S 2ND ST STE 101
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-4806
Practice Address - Country:US
Practice Address - Phone:918-696-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist