Provider Demographics
NPI:1477806909
Name:MOORE, MARY CHRISTINE (CFNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-1158
Mailing Address - Country:US
Mailing Address - Phone:662-371-1326
Mailing Address - Fax:662-371-1325
Practice Address - Street 1:1626 HIGHWAY 30 E
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655
Practice Address - Country:US
Practice Address - Phone:662-371-1326
Practice Address - Fax:662-371-1325
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000017955363LF0000X
MSR883220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAPN0000017955OtherADVANCED PRACTICE NURSE
RN0000196837OtherRN
MSR883220OtherNURSING LICENSE NUMBER
F0612635OtherFAMILY NURSE PRACTITIONER