Provider Demographics
NPI:1962050146
Name:MOATS, ELIZABETH JUNE FISH (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JUNE FISH
Last Name:MOATS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 W RAMPART ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8846
Mailing Address - Country:US
Mailing Address - Phone:317-421-2012
Mailing Address - Fax:317-398-1851
Practice Address - Street 1:2451 INTELLIPLEX DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8580
Practice Address - Country:US
Practice Address - Phone:317-392-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009271A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty