Provider Demographics
NPI:1093733149
Name:MOORE, MARILYN JOYCE (RN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:JOYCE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:JOYCE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4227 STOCKHOLM RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-2744
Mailing Address - Country:US
Mailing Address - Phone:218-724-1655
Mailing Address - Fax:
Practice Address - Street 1:503 E 3RD ST
Practice Address - Street 2:SUITE 400
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1905
Practice Address - Country:US
Practice Address - Phone:218-786-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 059747-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse