Healthcare Provider Details

I. General information

NPI: 1992786248
Provider Name (Legal Business Name): GINA L MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N MICHIGAN ST
ARGOS IN
46501-1134
US

IV. Provider business mailing address

1400 E 9TH ST
ROCHESTER IN
46975-8931
US

V. Phone/Fax

Practice location:
  • Phone: 574-892-5131
  • Fax: 574-223-5847
Mailing address:
  • Phone: 574-224-1044
  • Fax: 574-224-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001226A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: