Provider Demographics
NPI:1578061883
Name:MOFFETT, ANN N (NP-C)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:N
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JACOBS GULCH RD
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2023
Mailing Address - Country:US
Mailing Address - Phone:208-784-4612
Mailing Address - Fax:208-783-1342
Practice Address - Street 1:858 COMMERCE DR.
Practice Address - Street 2:
Practice Address - City:SMELTERVILLE
Practice Address - State:ID
Practice Address - Zip Code:83858
Practice Address - Country:US
Practice Address - Phone:208-784-4612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57731363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care