Provider Demographics
NPI:1316561202
Name:MOORE, THERESA LYNN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6267 40TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2344
Mailing Address - Country:US
Mailing Address - Phone:919-638-1209
Mailing Address - Fax:
Practice Address - Street 1:701 S PARKER ST STE 2800
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4720
Practice Address - Country:US
Practice Address - Phone:253-240-0530
Practice Address - Fax:480-546-3134
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61083112163W00000X
WARN61083112163W00000X
WA61114903363LP0808X
WAAP61114903363LP0808X
CANP95019703363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse