Individual
MARY MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
1980 HOLTON AVE E, BIG STONE GAP, VA 24219-3366
(276) 523-3111
Mailing address
999 EXECUTIVE PARK BLVD, SUITE 201, KINGSPORT, TN 37660-4632
(423) 224-3250
(423) 224-3258
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
0024049167
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
74012436
—
KY
Enumeration date
08/15/2006
Last updated
11/29/2007
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