Provider Demographics
NPI:1275975203
Name:MOORE, REBECCA J (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
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 1:4135 BELT LINE RD STE 124
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-5879
Mailing Address - Country:US
Mailing Address - Phone:469-495-9126
Mailing Address - Fax:
Practice Address - Street 1:4135 BELT LINE RD STE 124
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-5879
Practice Address - Country:US
Practice Address - Phone:469-495-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127973363LP0200X, 363LF0000X
CO196559163W00000X
CO0990816363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3530727-01Medicaid