Provider Demographics
NPI:1275684268
Name:MOORE, STACEY J (ARNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 17510
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41017-0510
Mailing Address - Country:US
Mailing Address - Phone:859-341-5550
Mailing Address - Fax:859-344-3782
Practice Address - Street 1:1955 DIXIE HWY
Practice Address - Street 2:STE C
Practice Address - City:FT WRIGHT
Practice Address - State:KY
Practice Address - Zip Code:41011-2792
Practice Address - Country:US
Practice Address - Phone:859-341-5550
Practice Address - Fax:859-344-3782
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3808P363LF0000X
KY1086649163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0677403Medicare PIN