Provider Demographics
NPI:1033141155
Name:MOORE, ANNETTE RENE (CNP)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:RENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 E COUNTY LINE RD
Practice Address - Street 2:STE 300
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1000
Practice Address - Country:US
Practice Address - Phone:317-497-2300
Practice Address - Fax:317-497-2502
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000750A363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000042207OtherANTHEM BCBS
IN100473980Medicaid
KY2439492000OtherPASSPORT ADVANTAGE
IN709911POtherSIHO
500012166OtherMEDICARE RAILROAD
KY1161025OtherPASSPORT KY MEDICAID
5012042OtherAETNA
KY78007887Medicaid
KY1161025OtherPASSPORT KY MEDICAID
KY2439492000OtherPASSPORT ADVANTAGE
IN412840BBMedicare PIN
P01857Medicare UPIN
IN266180674Medicare PIN
IN266180674Medicare PIN