Provider Demographics
NPI:1285747816
Name:MOORE, ZELLA (NP)
Entity type:Individual
Prefix:
First Name:ZELLA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 N ALPINE RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1449
Mailing Address - Country:US
Mailing Address - Phone:815-395-1500
Mailing Address - Fax:815-395-1415
Practice Address - Street 1:1639 N ALPINE RD
Practice Address - Street 2:SUITE 260
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1449
Practice Address - Country:US
Practice Address - Phone:815-395-1500
Practice Address - Fax:815-395-1415
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK30842Medicare PIN
ILQ71925Medicare UPIN