Provider Demographics
NPI:1114775046
Name:MOORE, TASHA RENAE (APRN)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:RENAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 VITTORIO DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-3449
Mailing Address - Country:US
Mailing Address - Phone:262-744-2115
Mailing Address - Fax:
Practice Address - Street 1:894 E ALTAMONTE DR
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5002
Practice Address - Country:US
Practice Address - Phone:407-834-5151
Practice Address - Fax:407-834-5562
Is Sole Proprietor?:No
Enumeration Date:2024-05-07
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11032086363L00000X
FLAPRN11032086363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner