Provider Demographics
NPI:1154609295
Name:LODGE-MOORE, DONNA MARIE (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:MARIE
Last Name:LODGE-MOORE
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:MS
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:LODGE-MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C, PMHNP-BC
Mailing Address - Street 1:1132 CARMADELLE ST
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-2646
Mailing Address - Country:US
Mailing Address - Phone:504-352-2565
Mailing Address - Fax:
Practice Address - Street 1:15 SW EVERETT MALL WAY STE A
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-2715
Practice Address - Country:US
Practice Address - Phone:504-352-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY526019363LF0000X
LAAP06526363LF0000X, 363LP0808X
CA21284363LF0000X, 363LP0808X
WAAP60359515363LF0000X, 363LP0808X
WAAP60359615363LP0808X
TXAP120751363LP0808X, 363LF0000X
NY402939363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2305999Medicaid
LA3D200DG35Medicare Oscar/Certification