Provider Demographics
NPI:1083148522
Name:MOORE, BLAKELY M (APRN)
Entity type:Individual
Prefix:
First Name:BLAKELY
Middle Name:M
Last Name:MOORE
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:BLAKELY
Other - Middle Name:M
Other - Last Name:EDMUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:449 JACK STEPHENS DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-686-8224
Practice Address - Fax:501-686-5548
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily