Basic Information
| Provider Information | |||||||||
| NPI: | 1558763474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | NINA | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5710 BAKER RD | ||||||||
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| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553455901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527674200 | ||||||||
| FaxNumber: | 9527674211 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 SILVER BELL RD | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551221653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514050384 | ||||||||
| FaxNumber: | 9527674211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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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 | 225XP0200X | 104762 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.