Provider Demographics
NPI:1588123996
Name:MOORE, STEPHANIE CHARIS
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHARIS
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 1:35 POND PATH
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1828
Mailing Address - Country:US
Mailing Address - Phone:631-672-2953
Mailing Address - Fax:
Practice Address - Street 1:301 SMITHTOWN BLVD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2080
Practice Address - Country:US
Practice Address - Phone:631-737-1492
Practice Address - Fax:631-588-0016
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY753451-1163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics