=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417958075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNA J MOATS C.R.N.P
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19426 LEITERSBURG PIKE
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742-1468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-513-6330
-----------------------------------------------------
Fax | 240-513-6332
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19426 LEITERSBURG PIKE
-----------------------------------------------------
City | HAGERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21742-1468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-513-6330
-----------------------------------------------------
Fax | 240-513-6332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R122100
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------