Provider Demographics
NPI:1104866722
Name:MORAN, CYNTHIA A (NP-C)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:MORAN
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 1:603 E GAINES DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-3205
Mailing Address - Country:US
Mailing Address - Phone:660-885-8141
Mailing Address - Fax:660-885-5815
Practice Address - Street 1:603 E GAINES DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-3205
Practice Address - Country:US
Practice Address - Phone:660-885-8141
Practice Address - Fax:660-885-5815
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO070350363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1104866722Medicaid
MO1104866722Medicaid