Provider Demographics
NPI:1295351013
Name:MOORE, LILLIAN A (PCT,CNA, PHLEBOTOMIS)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:PCT,CNA, PHLEBOTOMIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 PONDEROSA LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-6750
Mailing Address - Country:US
Mailing Address - Phone:386-283-3116
Mailing Address - Fax:
Practice Address - Street 1:26 PONDEROSA LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-6750
Practice Address - Country:US
Practice Address - Phone:386-283-3116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA269409374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty