Provider Demographics
NPI:1679709117
Name:MOORE, CASSANDRA (CNP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-4425
Mailing Address - Country:US
Mailing Address - Phone:715-822-2231
Mailing Address - Fax:
Practice Address - Street 1:1051 WEST AVE
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-4425
Practice Address - Country:US
Practice Address - Phone:715-719-0662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI89488363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner