Provider Demographics
NPI:1497014682
Name:MOORE, JILLIAN LEIGH (RN)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:LEIGH
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JILLIAN
Other - Middle Name:LEIGH
Other - Last Name:HUDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6839 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-494-0612
Mailing Address - Fax:918-392-4693
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146822367500000X
OK78700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8112UDOtherBCBS
TX8112UDOtherBCBS