Provider Demographics
NPI:1588164784
Name:MOORE, CHARLENE BETH (NP)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:BETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:BETH
Other - Last Name:BLOODWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1 PHIPPS LANE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944
Mailing Address - Country:US
Mailing Address - Phone:217-463-4340
Mailing Address - Fax:217-463-4342
Practice Address - Street 1:727 E COURT ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2460
Practice Address - Country:US
Practice Address - Phone:217-466-4194
Practice Address - Fax:217-466-4099
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018036363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily