Provider Demographics
NPI:1992783807
Name:MOORE, MELISSA JANE (RN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
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 1:2657 W 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MCCOY
Mailing Address - State:WI
Mailing Address - Zip Code:54656-5240
Mailing Address - Country:US
Mailing Address - Phone:608-388-3871
Mailing Address - Fax:608-388-7877
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9007
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health