MEDICARE: DONNA V MOORE RN

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	163W00000X	Registered Nurse	127391-030	WI

General Provider Information

NPI Number	:	1205075975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA V MOORE RN

Provider Business Mailing Address
First Line	:	8989 MID LAKE RD
Second Line	:
City	:	WOODRUFF
State	:	WI
Zip	:	54568-9610
Country	:	US
Telephone Number	:	715-358-5564
Fax Number	:

Provider Business Practice Location Address
First Line	:	8989 MID LAKE RD
Second Line	:
City	:	WOODRUFF
State	:	WI
Zip	:	54568-9610
Country	:	US
Telephone Number	:	715-358-5564
Fax Number	:

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

Provider Enumeration Date	:	02/19/2009
Last Update Date	:	02/19/2009

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