Provider Demographics
NPI:1972053908
Name:MOSS FRASER, LLOYREEN (MMP)
Entity type:Individual
Prefix:
First Name:LLOYREEN
Middle Name:
Last Name:MOSS FRASER
Suffix:
Gender:F
Credentials:MMP
Other - Prefix:
Other - First Name:REENIE
Other - Middle Name:
Other - Last Name:MOSS FRASER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MMP
Mailing Address - Street 1:813 DILIGENCE DR STE 121C
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:813 DILIGENCE DR STE 121C
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4285
Practice Address - Country:US
Practice Address - Phone:757-660-1796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019009793225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019009793OtherSTATE MASSAGE LICENSE NUMBER