Provider Demographics
NPI:1215549217
Name:MOORE, MARANDA J (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10812 ROB HILL RD
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-8108
Mailing Address - Country:US
Mailing Address - Phone:479-453-6216
Mailing Address - Fax:
Practice Address - Street 1:10812 ROB HILL RD
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-8108
Practice Address - Country:US
Practice Address - Phone:479-453-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR124571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily