Provider Demographics
NPI:1528347960
Name:MOORE, CHERYL ANN
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44645-9772
Mailing Address - Country:US
Mailing Address - Phone:330-855-3152
Mailing Address - Fax:
Practice Address - Street 1:89 PARK ST
Practice Address - Street 2:
Practice Address - City:MARSHALLVILLE
Practice Address - State:OH
Practice Address - Zip Code:44645-9772
Practice Address - Country:US
Practice Address - Phone:330-855-3152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2654891Medicaid