Provider Demographics
NPI:1316791387
Name:MOORE, AMANDA MICHELLE (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1742
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:
Practice Address - Street 1:746 CAMPBELL LN STE 101
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1000
Practice Address - Country:US
Practice Address - Phone:270-843-9510
Practice Address - Fax:270-843-9511
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY4018630363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily