Provider Demographics
NPI:1902254485
Name:MOORE, DEASIA
Entity type:Individual
Prefix:
First Name:DEASIA
Middle Name:
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 1:10 JOSEPHINE DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1000
Mailing Address - Country:US
Mailing Address - Phone:917-577-7791
Mailing Address - Fax:
Practice Address - Street 1:10 JOSEPHINE DR
Practice Address - Street 2:
Practice Address - City:WASHINGTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:10992-1000
Practice Address - Country:US
Practice Address - Phone:917-577-7791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2024-11-21
Deactivation Date:2018-02-08
Deactivation Code:
Reactivation Date:2024-11-21
Provider Licenses
StateLicense IDTaxonomies
NY323577164W00000X
NY722968163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No164W00000XNursing Service ProvidersLicensed Practical Nurse