Provider Demographics
NPI:1992997639
Name:MOSLEY, SUSAN LESLIE (LAC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LESLIE
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3006
Mailing Address - Country:US
Mailing Address - Phone:770-548-0172
Mailing Address - Fax:
Practice Address - Street 1:318 BROAD ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3006
Practice Address - Country:US
Practice Address - Phone:770-548-0172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA292171100000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist