Provider Demographics
NPI:1033179965
Name:MOORE, LINDA ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:LINDA
Other - Middle Name:ANN
Other - Last Name:DICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:6TH FLOOR C.S. MOTT CHILDREN'S HOSPITAL
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-4234
Practice Address - Country:US
Practice Address - Phone:734-936-4185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704241910363L00000X
OH08660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3039385Medicaid
MI4825084Medicaid
OH3039385Medicaid