Healthcare Provider Details

I. General information

NPI: 1790377695
Provider Name (Legal Business Name): JESSICA E. MOYER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3460 N RIDGE RD STE 120
WICHITA KS
67205-1223
US

IV. Provider business mailing address

3460 N RIDGE RD STE 120
WICHITA KS
67205-1223
US

V. Phone/Fax

Practice location:
  • Phone: 316-272-0800
  • Fax:
Mailing address:
  • Phone: 316-272-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number53-79992-082
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: