Provider Demographics
NPI:1033718903
Name:MOORE, LISA JO (NP-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JO
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:JO
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:861 S DRY GULCH RD
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-6708
Mailing Address - Country:US
Mailing Address - Phone:417-234-1026
Mailing Address - Fax:
Practice Address - Street 1:3033 S KANSAS EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5969
Practice Address - Country:US
Practice Address - Phone:417-881-7442
Practice Address - Fax:417-988-9844
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020011705363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily