Provider Demographics
NPI:1386663102
Name:MOORE, LAURA FADIL (CNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:FADIL
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:FADIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:281 SAWYER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-3409
Mailing Address - Country:US
Mailing Address - Phone:970-769-2214
Mailing Address - Fax:
Practice Address - Street 1:2390 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4638
Practice Address - Country:US
Practice Address - Phone:970-259-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO160465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21702781Medicaid
CO804351Medicare ID - Type Unspecified
CO21702781Medicaid