Provider Demographics
NPI:1689077927
Name:MOORE, MARY MAUDEANA (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MAUDEANA
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 RIVER RD APT E207
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-1338
Mailing Address - Country:US
Mailing Address - Phone:918-661-6180
Mailing Address - Fax:256-325-6724
Practice Address - Street 1:10 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705-5003
Practice Address - Country:US
Practice Address - Phone:701-723-5190
Practice Address - Fax:701-723-5391
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK114792363LF0000X
AL1-117717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200558940AMedicaid
OK200558940AMedicaid