Provider Demographics
NPI:1174938054
Name:MOORE, TRAKENA
Entity type:Individual
Prefix:
First Name:TRAKENA
Middle Name:
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:PO BOX 532
Mailing Address - Street 2:
Mailing Address - City:SASSER
Mailing Address - State:GA
Mailing Address - Zip Code:39885-0532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3015
Practice Address - Country:US
Practice Address - Phone:229-931-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN235919163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse