Provider Demographics
NPI:1326686395
Name:MOORE, JOANNA LEIGH (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:LEIGH
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:175-761-3353
Mailing Address - Fax:317-343-6562
Practice Address - Street 1:661 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-2662
Practice Address - Country:US
Practice Address - Phone:765-472-2519
Practice Address - Fax:765-400-4465
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28164395A363LF0000X
IN71009786A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300036259Medicaid