Healthcare Provider Details

I. General information

NPI: 1104811215
Provider Name (Legal Business Name): JILL M MOORE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 W SAGINAW RD
VASSAR MI
48768-9483
US

IV. Provider business mailing address

PO BOX 779
TAWAS CITY MI
48764-0779
US

V. Phone/Fax

Practice location:
  • Phone: 989-823-5020
  • Fax: 989-823-7881
Mailing address:
  • Phone: 855-298-9888
  • Fax: 989-497-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704173083
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: