Provider Demographics
NPI:1063481034
Name:MOORE, MARY (MOLLY) MCCAFFERY (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY (MOLLY)
Middle Name:MCCAFFERY
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MRS
Other - First Name:MARY (MOLLY)
Other - Middle Name:GANNON
Other - Last Name:MCCAFFERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:SCHOOL OF NURSING
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6200
Mailing Address - Fax:601-984-6214
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR843526363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS753068151OtherMS PHYSICIANS CARE NETWOR
MS00120621Medicaid
MS7206004OtherAETNA
MS753068151001OtherTRICARE
MS753068151OtherMS HEALTH PARTNERS
MS753068151001OtherTRICARE
MS00120621Medicaid