Provider Demographics
NPI:1114475019
Name:MOORE, ELIZABETH (CNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 WEALTHY ST SE STE 250
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2998
Practice Address - Country:US
Practice Address - Phone:616-774-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289705363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care