Provider Demographics
NPI:1073760864
Name:MOORE, DONNA H (NP-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:H
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1049
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-4049
Mailing Address - Country:US
Mailing Address - Phone:304-645-4043
Mailing Address - Fax:304-645-4713
Practice Address - Street 1:211 MERCHANTS WALK
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1901
Practice Address - Country:US
Practice Address - Phone:304-872-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV48550363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035222000Medicaid
WV48550OtherLICENSE
WVWV0987A760Medicare PIN
WV511827Medicare Oscar/Certification
WV5118271Medicare PIN
WV511897Medicare Oscar/Certification
WVD518361Medicare PIN