Healthcare Provider Details

I. General information

NPI: 1487199311
Provider Name (Legal Business Name): BRITTANY MOIST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2017
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W CHESTNUT ST
BLOOMINGTON IL
61701-2814
US

IV. Provider business mailing address

821 POPLAR ST
HIGHLAND IL
62249-1658
US

V. Phone/Fax

Practice location:
  • Phone: 309-557-1400
  • Fax:
Mailing address:
  • Phone: 618-654-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209015217
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.015217
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: