Healthcare Provider Details

I. General information

NPI: 1528143617
Provider Name (Legal Business Name): JOAN MARTIN MOORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

11 STEGOS DR
WALLINGFORD CT
06492-2563
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-6023
  • Fax: 860-714-8190
Mailing address:
  • Phone: 203-269-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number001792
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: