Provider Demographics
NPI:1588245013
Name:MOORE, CARISSA LAVERNE
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:LAVERNE
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 1:1680 S GREATHOUSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525
Mailing Address - Country:US
Mailing Address - Phone:580-297-6965
Mailing Address - Fax:580-324-4181
Practice Address - Street 1:1680 S GREATHOUSE DRIVE
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525
Practice Address - Country:US
Practice Address - Phone:580-297-6965
Practice Address - Fax:580-324-4181
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100683770AMedicaid