Basic Information
| Provider Information | |||||||||
| NPI: | 1104438688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | LAVERNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 NEW JERSEY AVE SE STE 845 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200033338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025456980 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1100 NEW JERSEY AVE SE STE 845 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200033338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025456980 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN1008911 | DC | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.