Healthcare Provider Details

I. General information

NPI: 1851483523
Provider Name (Legal Business Name): TINA L. MOORE APRN, BC-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

615 MAIN ST
NEW MADRID MO
63869-1513
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-6001
  • Fax:
Mailing address:
  • Phone: 573-748-2546
  • Fax: 573-472-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number141409
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: