Provider Demographics
NPI:1821326760
Name:MOORE, DIANE OLLIVE (ARNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:OLLIVE
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
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 856300
Mailing Address - Street 2:DEPT 125
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40285-6300
Mailing Address - Country:US
Mailing Address - Phone:502-937-3155
Mailing Address - Fax:502-935-0743
Practice Address - Street 1:8033 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258
Practice Address - Country:US
Practice Address - Phone:502-937-3155
Practice Address - Fax:502-935-0743
Is Sole Proprietor?:No
Enumeration Date:2009-12-04
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6250P363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0115002Medicare PIN