Provider Demographics
NPI:1790985679
Name:MOOSE, MARNIE ELLEN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MARNIE
Middle Name:ELLEN
Last Name:MOOSE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-3416
Mailing Address - Country:US
Mailing Address - Phone:304-465-1030
Mailing Address - Fax:304-469-9811
Practice Address - Street 1:502 MAIN ST W
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-3416
Practice Address - Country:US
Practice Address - Phone:304-465-1030
Practice Address - Fax:304-469-9811
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily