Provider Demographics
NPI:1104811215
Name:MOORE, JILL M (FNP-BC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:855-298-9888
Mailing Address - Fax:989-497-3162
Practice Address - Street 1:1212 W SAGINAW RD
Practice Address - Street 2:
Practice Address - City:VASSAR
Practice Address - State:MI
Practice Address - Zip Code:48768-9483
Practice Address - Country:US
Practice Address - Phone:989-823-5020
Practice Address - Fax:989-823-7881
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704173083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM10200335OtherTRICARE
MI150533OtherMEDICAID-GREATLAKES
MI0877585OtherBCBSMI
MI4708328Medicaid
0P11740Medicare ID - Type Unspecified
MI0877585OtherBCBSMI