Provider Demographics
NPI:1073500658
Name:MOORE, JEANNE (NP)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:MARIE CARNEY
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:2200 TACKETTS MILL DR
Mailing Address - Street 2:WOODBRIDGE
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3012
Mailing Address - Country:US
Mailing Address - Phone:703-494-4961
Mailing Address - Fax:
Practice Address - Street 1:2200 TACKETTS MILL DR
Practice Address - Street 2:WOODBRIDGE
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3012
Practice Address - Country:US
Practice Address - Phone:703-494-4961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 152237-0363L00000X
VA0024168326363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
23218OtherSIOUX VALLEY HEALTH PLAN
MN984639500Medicaid
1651881OtherAMERICA'S PPO
MN141044OtherUCARE MINNESOTA
500020824OtherPALMETTO GBA RAILROAD MCR
01-07324OtherMEDICA
MN062J3CAOtherBLUE CROSS BLUE SHIELD
NA2081029811OtherPREFERRED ONE
01-07324OtherMEDICA
500020824OtherPALMETTO GBA RAILROAD MCR