Provider Demographics
NPI:1588256846
Name:MOOR, LYDIA MARIE (CNP)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:MARIE
Last Name:MOOR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MISS
Other - First Name:LYDIA
Other - Middle Name:MARIE
Other - Last Name:THATCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 E JEFFERSON ST STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6221
Practice Address - Country:US
Practice Address - Phone:208-322-1680
Practice Address - Fax:208-322-1695
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ250264363LA2100X
ID66852363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty