Provider Demographics
NPI:1699173120
Name:MOORE, MARY ANNE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38850 STATE ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:REEDSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45772-9724
Mailing Address - Country:US
Mailing Address - Phone:740-985-3304
Mailing Address - Fax:
Practice Address - Street 1:38850 STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:REEDSVILLE
Practice Address - State:OH
Practice Address - Zip Code:45772-9724
Practice Address - Country:US
Practice Address - Phone:740-985-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH306626390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH306626Medicaid