Provider Demographics
NPI:1386957090
Name:MOORE, BRENDA MARGARET (LPN)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:MARGARET
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:MARGARET
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:5502 ST. RT 36
Mailing Address - Street 2:#48
Mailing Address - City:MT MORRIS
Mailing Address - State:NY
Mailing Address - Zip Code:14510
Mailing Address - Country:US
Mailing Address - Phone:585-658-2545
Mailing Address - Fax:
Practice Address - Street 1:5502 ST. RT 36
Practice Address - Street 2:#48
Practice Address - City:MT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510
Practice Address - Country:US
Practice Address - Phone:585-658-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277832-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse