Provider Demographics
NPI:1669031266
Name:MOORE, JODIE H (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:H
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:H
Other - Last Name:MARSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BOSWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74727
Mailing Address - Country:US
Mailing Address - Phone:580-566-2530
Mailing Address - Fax:580-566-2533
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:BOSWELL
Practice Address - State:OK
Practice Address - Zip Code:74727-7472
Practice Address - Country:US
Practice Address - Phone:580-566-2530
Practice Address - Fax:580-566-2533
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK86293363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily