Healthcare Provider Details

I. General information

NPI: 1730915067
Provider Name (Legal Business Name): MADILYN DIANE MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

IV. Provider business mailing address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-9189
  • Fax:
Mailing address:
  • Phone: 317-880-9189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28264395A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: