MEDICARE: MS. LISA JO MOORE NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2020011705	MO
2	363L00000X	Nurse Practitioner	2020011705	MO

General Provider Information

NPI Number	:	1033718903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA JO MOORE NP-C

Provider Business Mailing Address
First Line	:	861 S DRY GULCH RD
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-6708
Country	:	US
Telephone Number	:	417-234-1026
Fax Number	:

Provider Business Practice Location Address
First Line	:	3033 S KANSAS EXPY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-5969
Country	:	US
Telephone Number	:	417-881-7442
Fax Number	:	417-988-9844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2020
Last Update Date	:	12/17/2020

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