Provider Demographics
NPI:1366746257
Name:MOORE, BETTY KAREN (FNP)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:KAREN
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5515 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9670
Mailing Address - Country:US
Mailing Address - Phone:269-429-9644
Mailing Address - Fax:269-429-4002
Practice Address - Street 1:5515 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9670
Practice Address - Country:US
Practice Address - Phone:269-429-9644
Practice Address - Fax:269-429-4002
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282019363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1366746257Medicaid
MI1366746257Medicaid