MEDICARE: STACEY J MOORE ARNP

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	3808P	KY
2	163WW0101X	Ambulatory Women's Health Care Registered Nurse	1086649	KY

General Provider Information

NPI Number	:	1275684268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY J MOORE ARNP

Provider Business Mailing Address
First Line	:	PO BOX 17510
Second Line	:
City	:	COVINGTON
State	:	KY
Zip	:	41017-0510
Country	:	US
Telephone Number	:	859-341-5550
Fax Number	:	859-344-3782

Provider Business Practice Location Address
First Line	:	1955 DIXIE HWY
Second Line	:	STE C
City	:	FT WRIGHT
State	:	KY
Zip	:	41011-2792
Country	:	US
Telephone Number	:	859-341-5550
Fax Number	:	859-344-3782

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	08/28/2012

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