Provider Demographics
NPI:1164799797
Name:MOORE, ANNIE WALDRUM (NP)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:WALDRUM
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 BROADWAY
Mailing Address - Street 2:UNIT 3
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4158
Mailing Address - Country:US
Mailing Address - Phone:205-915-5216
Mailing Address - Fax:
Practice Address - Street 1:101 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-3766
Practice Address - Country:US
Practice Address - Phone:781-272-4667
Practice Address - Fax:781-270-4196
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2270524363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health