Provider Demographics
NPI:1073266722
Name:MOORE, BERTHA JEAN (RN)
Entity Type:Individual
Prefix:MS
First Name:BERTHA
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:236 MIDWAY
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-5051
Mailing Address - Country:US
Mailing Address - Phone:650-799-1017
Mailing Address - Fax:
Practice Address - Street 1:236 MIDWAY
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-5051
Practice Address - Country:US
Practice Address - Phone:650-799-1017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN070305163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care