Healthcare Provider Details

I. General information

NPI: 1003577925
Provider Name (Legal Business Name): MEGHAN M MOORE MSN, AGACNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 112A
CREVE COEUR MO
63141-8252
US

IV. Provider business mailing address

7050 DARTMOUTH AVE
SAINT LOUIS MO
63130-2314
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6339
  • Fax: 314-251-4564
Mailing address:
  • Phone: 314-560-9498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2017043285
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2021039037
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: