Provider Demographics
NPI:1699980987
Name:MOORE, JOAN M (ARNP)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 ESTILL STREET
Mailing Address - Street 2:CPO 2174
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-0001
Mailing Address - Country:US
Mailing Address - Phone:859-985-3212
Mailing Address - Fax:859-985-3910
Practice Address - Street 1:305 ESTILL ST
Practice Address - Street 2:CPO 2174
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1742
Practice Address - Country:US
Practice Address - Phone:859-985-3212
Practice Address - Fax:859-985-3910
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY1353P390200000X
KY3001353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1063917OtherRN LICENSE
KY1353POtherARNP LICENSE