Provider Demographics
NPI:1699321646
Name:MOORE, HEIDI (CNP)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 ASHLAND RD STE 205
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2156
Mailing Address - Country:US
Mailing Address - Phone:567-345-3030
Mailing Address - Fax:567-345-3031
Practice Address - Street 1:1033 ASHLAND RD STE 205
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44905-2156
Practice Address - Country:US
Practice Address - Phone:567-345-3030
Practice Address - Fax:567-345-3031
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025450363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily