MEDICARE: ANDREA DIANE MOORE FNP-BC

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	2021039559	IL

General Provider Information

NPI Number	:	1710645544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA DIANE MOORE FNP-BC

Provider Business Mailing Address
First Line	:	425 E STATE ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2125
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 E STATE ST
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-2125
Country	:	US
Telephone Number	:	217-408-1195
Fax Number	:

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

Provider Enumeration Date	:	11/29/2021
Last Update Date	:	01/09/2026

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