Provider Demographics
NPI:1750316758
Name:MOORE, CAROLYN LEWIS (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LEWIS
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45456
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70895
Mailing Address - Country:US
Mailing Address - Phone:225-445-4399
Mailing Address - Fax:
Practice Address - Street 1:1718 NORTH FOSTER DR
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-445-4399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN075293 AP03576363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1567981Medicaid
LA4B389C822Medicare PIN
LA1567981Medicaid