Healthcare Provider Details

I. General information

NPI: 1295654812
Provider Name (Legal Business Name): LISA MARIE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 4TH ST SW APT 43
MINOT ND
58701-7377
US

IV. Provider business mailing address

312 19TH ST NW
MINOT ND
58703-2940
US

V. Phone/Fax

Practice location:
  • Phone: 218-340-8964
  • Fax:
Mailing address:
  • Phone: 218-340-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number$$$$$$$$$
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: