Provider Demographics
NPI:1508314691
Name:MOORE, ELIZABETH (CPM LM)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CPM LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11029 QUAKER VALLEY RD
Mailing Address - Street 2:P.O. BOX 235
Mailing Address - City:CAZENOVIA
Mailing Address - State:WI
Mailing Address - Zip Code:53924-8214
Mailing Address - Country:US
Mailing Address - Phone:608-415-7813
Mailing Address - Fax:
Practice Address - Street 1:11029 QUAKER VALLEY RD
Practice Address - Street 2:
Practice Address - City:CAZENOVIA
Practice Address - State:WI
Practice Address - Zip Code:53924-8214
Practice Address - Country:US
Practice Address - Phone:608-415-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-17
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI154-49176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI154-49OtherSTATE OF WISCONSIN LICENSE
15070010OtherTHE NORTH AMERICAN REGISTRY OF MIDWIVES