Healthcare Provider Details

I. General information

NPI: 1598686032
Provider Name (Legal Business Name): SUSAN R MOORE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RODEO RD APT 510
SANTA FE NM
87505-6359
US

IV. Provider business mailing address

500 RODEO RD APT 510
SANTA FE NM
87505-6359
US

V. Phone/Fax

Practice location:
  • Phone: 808-633-0929
  • Fax:
Mailing address:
  • Phone: 808-633-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR47608
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: