Healthcare Provider Details

I. General information

NPI: 1538937339
Provider Name (Legal Business Name): ELIZABETH MOORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 E HERITAGE PKWY
FARMINGTON AR
72730-5529
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 479-400-1140
  • Fax:
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-301-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number221593
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: