Provider Demographics
NPI:1336643410
Name:MOORE, LISA MARCELLA (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARCELLA
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARCELLA
Other - Last Name:BREYMIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:409 SE GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:47394-9464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 SE GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-9464
Practice Address - Country:US
Practice Address - Phone:765-584-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022576363LF0000X
IN71008271A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily