Provider Demographics
NPI:1053955567
Name:MOORE, SHERISA (DOULA , IBCLC)
Entity type:Individual
Prefix:
First Name:SHERISA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DOULA , IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RIVER CHASE DRIVE
Mailing Address - Street 2:B
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144
Mailing Address - Country:US
Mailing Address - Phone:518-291-0542
Mailing Address - Fax:
Practice Address - Street 1:17 RIVER CHASE DRIVE
Practice Address - Street 2:B
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144
Practice Address - Country:US
Practice Address - Phone:518-291-0542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374J00000X
NY631514-1163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No374J00000XNursing Service Related ProvidersDoula