Provider Demographics
NPI:1033708623
Name:MOORE, MARTY JO (RN)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:JO
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:JO
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:2020 W SPAULDING ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3551
Mailing Address - Country:US
Mailing Address - Phone:208-721-2045
Mailing Address - Fax:
Practice Address - Street 1:2020 W SPAULDING ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3551
Practice Address - Country:US
Practice Address - Phone:208-721-2045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDZC248462KOtherDL