Provider Demographics
NPI:1588653307
Name:MOORE, JANICE MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 996
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-0996
Mailing Address - Country:US
Mailing Address - Phone:405-226-0163
Mailing Address - Fax:
Practice Address - Street 1:9205 STANTON L YOUNG BLVD, WP2430
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-3251
Practice Address - Country:US
Practice Address - Phone:405-271-7449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKN3097006363L00000X
OKR0053173363L00000X
MO2013042559363L00000X
TX536444363L00000X
TXAP125297363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100180710AMedicaid
OK100180710AMedicaid
OK2486600604Medicare PIN