Provider Demographics
NPI:1821016965
Name:MOORE, TERRI L (NP)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
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 1188
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 HICKORY STREET NW
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1700
Practice Address - Country:US
Practice Address - Phone:541-812-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR083038699RN163W00000X
OR083038699N7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210824Medicaid
ORS81188Medicare UPIN
ORS81188Medicare UPIN
OR121379Medicare ID - Type Unspecified