Healthcare Provider Details

I. General information

NPI: 1093733149
Provider Name (Legal Business Name): MARILYN JOYCE MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN JOYCE JOHNSON

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 E 3RD ST SUITE 400
DULUTH MN
55805-1905
US

IV. Provider business mailing address

4227 STOCKHOLM RD
DULUTH MN
55803-2744
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-2370
  • Fax:
Mailing address:
  • Phone: 218-724-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 059747-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: