Provider Demographics
NPI:1619406949
Name:MOORE, BAILIE N (APRN)
Entity Type:Individual
Prefix:
First Name:BAILIE
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3232 N NORTHHILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4005
Mailing Address - Country:US
Mailing Address - Phone:479-587-1700
Mailing Address - Fax:479-587-1366
Practice Address - Street 1:3232 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4005
Practice Address - Country:US
Practice Address - Phone:479-587-1700
Practice Address - Fax:479-587-1366
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner