Provider Demographics
NPI:1417958075
Name:MOATS, JEANNA J (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:JEANNA
Middle Name:J
Last Name:MOATS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19426 LEITERSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1468
Mailing Address - Country:US
Mailing Address - Phone:240-513-6330
Mailing Address - Fax:240-513-6332
Practice Address - Street 1:19426 LEITERSBURG PIKE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1468
Practice Address - Country:US
Practice Address - Phone:240-513-6330
Practice Address - Fax:240-513-6332
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR122100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMM0432485OtherDEA
PA100730726034OtherMEDICAID GROUP #
PA50074538OtherCAPITAL BLUECROSS
PAUP006320BOtherLICENSE
P09564Medicare UPIN
PA25-1716306OtherDEVON
PA25-1716306OtherINTERGROUP
PAMM0432485OtherDEA
PA102401674 0001Medicaid
PA25-1716306OtherHEALTHNET/TRICARE
PAG920-0046/KDM4POOtherCAREFIRST
PA039204LN7Medicare PIN
PA436064OtherHEALTH AMERICA