Provider Demographics
NPI:1073829750
Name:MOORE, AMY (RN CDE)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3128 CHIPPEWA RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-4504
Mailing Address - Country:US
Mailing Address - Phone:952-649-0955
Mailing Address - Fax:
Practice Address - Street 1:6401 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4341
Practice Address - Country:US
Practice Address - Phone:763-502-4877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 956714163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator