Provider Demographics
NPI:1619392172
Name:MOORE, MELISSA ROSE (CNM, CNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ROSE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNM, CNP, PMHNP-BC
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LEMORIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 11TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2105
Mailing Address - Country:US
Mailing Address - Phone:810-923-6043
Mailing Address - Fax:505-727-4505
Practice Address - Street 1:1111 11TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2105
Practice Address - Country:US
Practice Address - Phone:810-923-6043
Practice Address - Fax:505-727-4505
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-78727163W00000X
NM670367A00000X
NM77534363LP0808X
MI4704257647163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31902243Medicaid
NM31902243Medicaid