Provider Demographics
NPI:1376741462
Name:FREEMAN-MOORE, DIANNE (NP)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:FREEMAN-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 1:819 WOODMERE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-5604
Mailing Address - Country:US
Mailing Address - Phone:765-448-4646
Mailing Address - Fax:765-448-4791
Practice Address - Street 1:819 WOODMERE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5604
Practice Address - Country:US
Practice Address - Phone:765-448-4646
Practice Address - Fax:765-448-4791
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002438A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71002438AOtherSTATE LICENSE
IN200865610Medicaid
IN71002438AOtherSTATE LICENSE