Provider Demographics
NPI:1003242256
Name:MOORE, WENDY M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 28TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8743
Mailing Address - Country:US
Mailing Address - Phone:701-404-1100
Mailing Address - Fax:701-540-6498
Practice Address - Street 1:901 28TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-404-1100
Practice Address - Fax:701-540-6498
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR36755363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner