Provider Demographics
NPI:1588700538
Name:MOORE, EILEEN M (APRN)
Entity type:Individual
Prefix:MRS
First Name:EILEEN
Middle Name:M
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 1:108 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2645
Mailing Address - Country:US
Mailing Address - Phone:860-889-3052
Mailing Address - Fax:860-889-0926
Practice Address - Street 1:108 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2645
Practice Address - Country:US
Practice Address - Phone:860-889-3052
Practice Address - Fax:860-889-0926
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001598363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001598OtherAPRN LICENSE NUMBER
CT004183365Medicaid
CT001598OtherAPRN LICENSE NUMBER
S541575Medicare UPIN