Healthcare Provider Details

I. General information

NPI: 1265623078
Provider Name (Legal Business Name): MISTY LYNNE MOORE FNPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5563 FAR HILLS AVE
DAYTON OH
45429-2225
US

IV. Provider business mailing address

5563 FAR HILLS AVE
DAYTON OH
45429-2225
US

V. Phone/Fax

Practice location:
  • Phone: 937-231-2300
  • Fax: 937-291-2303
Mailing address:
  • Phone: 937-231-2300
  • Fax: 937-291-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.019820
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-311363
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: