Provider Demographics
NPI:1801223946
Name:MOORE, HEATHER A (RN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
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 2106
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2106
Mailing Address - Country:US
Mailing Address - Phone:208-523-5319
Mailing Address - Fax:208-523-5627
Practice Address - Street 1:1970 E 17TH ST
Practice Address - Street 2:STE. 207
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8014
Practice Address - Country:US
Practice Address - Phone:208-523-5319
Practice Address - Fax:208-523-5627
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-38418163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse