Provider Demographics
NPI:1144576232
Name:MOORE, REBEKAH (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 S WALKER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403
Mailing Address - Country:US
Mailing Address - Phone:812-369-4344
Mailing Address - Fax:812-369-4314
Practice Address - Street 1:654 S WALKER ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-369-4344
Practice Address - Fax:812-369-4314
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004002A363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201109040Medicaid
IN201109040Medicaid