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General NPI Number Information
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NPI Number | 1578780961
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Entity Type | Individual
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Provider Name | LISA JUNE MOORE NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 11/21/2023
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Provider Practice Location Address
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Address Line | SIMPLY YOU HEALTH & MEDSPA 219 S. WOODDALE AVE.
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City | EAGLE
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State | ID
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Zip | 83616
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Country | US
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Telephone | 208-994-5576
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Fax | 208-529-6428
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Provider Business Mailing Address
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Address Line | 163 W. FLOATING FEATHER RD
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City | EAGLE
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State | ID
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Zip | 83616
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Country | US
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Telephone | 208-419-6499
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Fax | 208-529-6428
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | NP 669-A
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | NP 669-A
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License Number State | ID
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