Provider Demographics
NPI:1700361110
Name:MOORE, AMANDA DAWN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DAWN
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 1:7296 D 1376 RD
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-6008
Mailing Address - Country:US
Mailing Address - Phone:580-272-3500
Mailing Address - Fax:
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-421-4532
Practice Address - Fax:580-421-4572
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0074299363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily