Provider Demographics
NPI:1104167386
Name:MOORE, ANN ROBERTS (NP)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:ROBERTS
Last Name:MOORE
Suffix:
Gender:
Credentials:NP
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Mailing Address - Street 1:3245 HEALTH DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-3245
Mailing Address - Country:US
Mailing Address - Phone:574-647-1840
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:500 ARCADE AVE
Practice Address - Street 2:STE 210
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2485
Practice Address - Country:US
Practice Address - Phone:574-389-5656
Practice Address - Fax:574-523-7891
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2025-05-01
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Provider Licenses
StateLicense IDTaxonomies
IN71003777A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300012625Medicaid