Basic Information
Provider Information | |||||||||
NPI: | 1194983718 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | PIERCE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUD, CCC-A, F-AAA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PIERCE | ||||||||
OtherFirstName: | ANDREA | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AUD, CCC-A, F-AAA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11945 SAN JOSE BLVD | ||||||||
Address2: | #300 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322231613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9043961725 | ||||||||
FaxNumber: | 9043991717 | ||||||||
Practice Location | |||||||||
Address1: | 4203 BELFORT RD | ||||||||
Address2: | SUITE 340 | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322161409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048800911 | ||||||||
FaxNumber: | 9048809388 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2008 | ||||||||
LastUpdateDate: | 06/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY1430 | FL | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.