Healthcare Provider Details

I. General information

NPI: 1457001281
Provider Name (Legal Business Name): HEATHER MAE MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W EDISON RD STE 122
MISHAWAKA IN
46545-2784
US

IV. Provider business mailing address

620 W EDISON RD STE 122
MISHAWAKA IN
46545-2784
US

V. Phone/Fax

Practice location:
  • Phone: 574-855-4475
  • Fax:
Mailing address:
  • Phone: 574-855-4475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number28272283A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: