Provider Demographics
NPI:1992112361
Name:MOORE, MICHELLE LEJAY
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEJAY
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 1:209 E MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-3207
Mailing Address - Country:US
Mailing Address - Phone:972-551-0038
Mailing Address - Fax:972-551-1821
Practice Address - Street 1:209 E MOORE AVE
Practice Address - Street 2:
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160-3207
Practice Address - Country:US
Practice Address - Phone:972-551-0038
Practice Address - Fax:972-551-1821
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01596172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker