Provider Demographics
NPI:1427320811
Name:MOORE, MELISSA A (APRN)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:318 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-2337
Mailing Address - Country:US
Mailing Address - Phone:270-251-3223
Mailing Address - Fax:270-251-3220
Practice Address - Street 1:318 S 7TH ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066
Practice Address - Country:US
Practice Address - Phone:270-251-3223
Practice Address - Fax:270-251-3220
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007377363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100090800OtherMEDICAID GROUP
KY3007377OtherAPRN LIC
KY193400000XOtherTAXONOMY GROUP
KY7100226010Medicaid
KY000000782080OtherANTHEM
KY193400000XOtherTAXONOMY GROUP