Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225000000X | Orthotic Fitter |
NPI | 1235722968 |
---|---|
Provider Name | Teniqua Moffatte |
First Address | Douglasville, GA 30134-3249 |
Second Address | Douglasville, GA 30134-3249 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2021 |
Last Update Date | 13/02/2021 |