Healthcare Provider Details

I. General information

NPI: 1952639486
Provider Name (Legal Business Name): MARY DONOHUE MOORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

PO BOX 810
HANOVER NH
03755-0810
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SX0200X
TaxonomyOncology Clinical Nurse Specialist
License Number101.0058235
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number112014-23
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number101.0058235
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: