Provider Demographics
NPI:1275839706
Name:MOORE, MICHELE A (NP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
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 1:511 BISON BLVD
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1923
Mailing Address - Country:US
Mailing Address - Phone:260-927-4198
Mailing Address - Fax:260-499-4233
Practice Address - Street 1:45 N 250 W
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-8667
Practice Address - Country:US
Practice Address - Phone:260-499-4233
Practice Address - Fax:260-499-4235
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28159229163W00000X
IN71003528A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000697704OtherANTHEM
IN201010140Medicaid
INM400024082Medicare PIN