Provider Demographics
NPI:1215137138
Name:MOORE, LESLIE VICTORIA (RN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:VICTORIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:GOYETTE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1209 PERUVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-9716
Mailing Address - Country:US
Mailing Address - Phone:607-898-4727
Mailing Address - Fax:
Practice Address - Street 1:1209 PERUVILLE RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:NY
Practice Address - Zip Code:13073-9716
Practice Address - Country:US
Practice Address - Phone:607-898-4727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY550126163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02663587Medicaid