Provider Demographics
NPI:1063465482
Name:MOORE IVY, MISTY (CRNP)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:MOORE IVY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:ANN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1350 FORREST LAKE CV
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-7500
Mailing Address - Country:US
Mailing Address - Phone:901-759-2322
Mailing Address - Fax:
Practice Address - Street 1:7203 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1906
Practice Address - Country:US
Practice Address - Phone:901-759-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11904363LF0000X
MSR860233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406746100Medicaid
MDQ35825Medicare UPIN
MDK571Medicare ID - Type UnspecifiedINDIVIDUAL
MDKR59JHMedicare ID - Type UnspecifiedGROUP