Provider Demographics
NPI:1578780961
Name:MOORE, LISA JUNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JUNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:163 W. FLOATING FEATHER RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-419-6499
Mailing Address - Fax:208-529-6428
Practice Address - Street 1:SIMPLY YOU HEALTH & MEDSPA
Practice Address - Street 2:219 S. WOODDALE AVE.
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-994-5576
Practice Address - Fax:208-529-6428
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDNP 669-A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner