Provider Demographics
NPI:1326479841
Name:MOORE, MARY BETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
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 1:4100 JOHNSON RD STE 208
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2372
Mailing Address - Country:US
Mailing Address - Phone:740-314-5138
Mailing Address - Fax:740-792-4171
Practice Address - Street 1:4100 JOHNSON RD STE 208
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2372
Practice Address - Country:US
Practice Address - Phone:740-314-5138
Practice Address - Fax:740-792-4171
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.15343363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0095300Medicaid
OHH248402Medicare PIN