Provider Demographics
NPI:1457001281
Name:MOORE, HEATHER MAE (RN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W EDISON RD STE 122
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-2784
Mailing Address - Country:US
Mailing Address - Phone:574-855-4475
Mailing Address - Fax:
Practice Address - Street 1:620 W EDISON RD STE 122
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2784
Practice Address - Country:US
Practice Address - Phone:574-855-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28272283A163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice