Provider Demographics
NPI:1356660195
Name:MOORE, REBECCA LYNN (CRNP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:ELENBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MCA410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:905 W GOVERNOR RD
Practice Address - Street 2:SUITE 250
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2310
Practice Address - Country:US
Practice Address - Phone:717-531-7235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2017-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010716363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031501200001Medicaid