Healthcare Provider Details

I. General information

NPI: 1376741462
Provider Name (Legal Business Name): DIANNE FREEMAN-MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 WOODMERE DR
LAFAYETTE IN
47905-5604
US

IV. Provider business mailing address

819 WOODMERE DR
LAFAYETTE IN
47905-5604
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4646
  • Fax: 765-448-4791
Mailing address:
  • Phone: 765-448-4646
  • Fax: 765-448-4791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71002438A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: