Provider Demographics
NPI:1215979299
Name:MOORE, MICHELE (RD)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WASHIGNTON STREET
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1612
Practice Address - Country:US
Practice Address - Phone:717-221-6258
Practice Address - Fax:717-657-7390
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001736133N00000X
PA504822133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016757810003Medicaid
7574341OtherAETNA
2818240OtherAETNA HMO
PADN001736OtherLICENSE
2818240OtherAETNA HMO