Healthcare Provider Details

I. General information

NPI: 1821811407
Provider Name (Legal Business Name): JOEL MOORE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 05/31/2026
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7717 N ORANGE PRAIRIE RD
PEORIA IL
61615-9323
US

IV. Provider business mailing address

7717 N ORANGE PRAIRIE RD
PEORIA IL
61615-9323
US

V. Phone/Fax

Practice location:
  • Phone: 309-210-4663
  • Fax:
Mailing address:
  • Phone: 309-210-4663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041350663
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: