Provider Demographics
NPI:1568200541
Name:MOORE, ANJELICA (MD FAMILY PRACTICE)
Entity type:Individual
Prefix:DR
First Name:ANJELICA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD FAMILY PRACTICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 CHERRY ST SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 CHERRY ST SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-685-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)