Provider Demographics
NPI:1548229602
Name:MOORE, ALLISON D (CRNP)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:D
Last Name:MOORE
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 1:1901 MELBA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-794-6611
Mailing Address - Fax:334-794-6614
Practice Address - Street 1:1901 MELBA DRIVE
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-794-6611
Practice Address - Fax:334-794-6614
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1081292363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL00012172Medicaid
AL051512172OtherBLUE CROSS BLUE SHIELD
P39069Medicare UPIN
AL051512172OtherBLUE CROSS BLUE SHIELD
AL00012172Medicare PIN