Healthcare Provider Details

I. General information

NPI: 1528330305
Provider Name (Legal Business Name): ANDREA MARIE MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 KINGS HWY SUITE 340
SHREVEPORT LA
71103-3950
US

IV. Provider business mailing address

2600 KINGS HWY SUITE 340
SHREVEPORT LA
71103-3950
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-8620
  • Fax: 318-212-8625
Mailing address:
  • Phone: 318-212-8620
  • Fax: 318-212-8625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAPRN047672
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: