Provider Demographics
NPI:1124662531
Name:MOORE, DOROTHY M (HOMEMAKER)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:HOMEMAKER
Other - Prefix:MISS
Other - First Name:DOROTHY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HOMEMAKER
Mailing Address - Street 1:2211 HIGHWAY 45 N STE G2211
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-2730
Mailing Address - Country:US
Mailing Address - Phone:601-616-0551
Mailing Address - Fax:601-282-5009
Practice Address - Street 1:2211 HIGHWAY 45 N STE G2211
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-2730
Practice Address - Country:US
Practice Address - Phone:601-616-0551
Practice Address - Fax:601-282-5009
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSBL20190001274376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty