Healthcare Provider Details

I. General information

NPI: 1164864153
Provider Name (Legal Business Name): CHRISTINE MOORE WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10495 MONTGOMERY RD STE 25
MONTGOMERY OH
45242-4420
US

IV. Provider business mailing address

10495 MONTGOMERY RD STE 25
MONTGOMERY OH
45242-4420
US

V. Phone/Fax

Practice location:
  • Phone: 513-865-1631
  • Fax:
Mailing address:
  • Phone: 513-865-1631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberCOA.14143-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN.CNP.14143
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: