Healthcare Provider Details

I. General information

NPI: 1932031168
Provider Name (Legal Business Name): LISA ANN MOORE AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 DOGWOOD DR
BUELLTON CA
93427-6809
US

IV. Provider business mailing address

360 DOGWOOD DR
BUELLTON CA
93427-6809
US

V. Phone/Fax

Practice location:
  • Phone: 805-453-4218
  • Fax:
Mailing address:
  • Phone: 805-453-4218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95031277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: