Provider Demographics
NPI:1003577925
Name:MOORE, MEGHAN M (MSN, AGACNP, FNP)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSN, AGACNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7050 DARTMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2314
Mailing Address - Country:US
Mailing Address - Phone:314-560-9498
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD STE 112A
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-8252
Practice Address - Country:US
Practice Address - Phone:314-251-6339
Practice Address - Fax:314-251-4564
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2021039037363LF0000X
MO2017043285363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily