Provider Demographics
NPI:1124395694
Name:MOORE, AVIS MARIE (RN)
Entity Type:Individual
Prefix:
First Name:AVIS
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S 6TH ST
Mailing Address - Street 2:GOV. CENTER A-14
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55487-0999
Mailing Address - Country:US
Mailing Address - Phone:612-596-1223
Mailing Address - Fax:
Practice Address - Street 1:300 S 6TH ST
Practice Address - Street 2:GOV. CENTER A-14
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55487-0999
Practice Address - Country:US
Practice Address - Phone:612-596-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR121109-2163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse