Provider Demographics
NPI:1801829759
Name:MOORE, CONSTANCE LUCILLE (CRNA)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:LUCILLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
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 668
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80001-0668
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:303-422-9474
Practice Address - Street 1:9395 CROWN CREST BLVD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8573
Practice Address - Country:US
Practice Address - Phone:303-269-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45141367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05828384Medicaid
CO05828384Medicaid