Healthcare Provider Details

I. General information

NPI: 1164799797
Provider Name (Legal Business Name): ANNIE WALDRUM MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CAMBRIDGE ST
BURLINGTON MA
01803-3766
US

IV. Provider business mailing address

452 BROADWAY UNIT 3
CAMBRIDGE MA
02138-4158
US

V. Phone/Fax

Practice location:
  • Phone: 781-272-4667
  • Fax: 781-270-4196
Mailing address:
  • Phone: 205-915-5216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN2270524
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: