Provider Demographics
NPI:1568106482
Name:MOORE, MARILYN JEANNE (RN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:JEANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:JEANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:CRISIS INTERVENTION CENTER
Mailing Address - Street 2:1003 PARK ST
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-713-9095
Mailing Address - Fax:
Practice Address - Street 1:CRISIS INTERVENTION CENTER
Practice Address - Street 2:1003 PARK ST
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669
Practice Address - Country:US
Practice Address - Phone:315-713-9095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY464455163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse