Provider Demographics
NPI:1619094182
Name:MOORE, SUE E (MS RN CNS)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS RN CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 S GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5334
Mailing Address - Country:US
Mailing Address - Phone:614-221-3141
Mailing Address - Fax:614-221-4870
Practice Address - Street 1:270 S GRANT AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5334
Practice Address - Country:US
Practice Address - Phone:614-221-3141
Practice Address - Fax:614-221-4870
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS 05125364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP59852Medicare UPIN