Healthcare Provider Details

I. General information

NPI: 1275839706
Provider Name (Legal Business Name): MICHELE A MOORE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 N 250 W
LAGRANGE IN
46761-8667
US

IV. Provider business mailing address

511 BISON BLVD
KENDALLVILLE IN
46755-1923
US

V. Phone/Fax

Practice location:
  • Phone: 260-499-4233
  • Fax: 260-499-4235
Mailing address:
  • Phone: 260-927-4198
  • Fax: 260-499-4233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28159229
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003528A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: