Basic Information
| Provider Information | |||||||||
| NPI: | 1518356922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | LATRICE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 437 WATERBURY WAY | ||||||||
| Address2: | |||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301346079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784815334 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 JESSE HILL JR DR SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303033031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046161000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2015 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 190546 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.