Provider Demographics
NPI:1861663494
Name:MOORE, PATRYCE JEANALE
Entity Type:Individual
Prefix:
First Name:PATRYCE
Middle Name:JEANALE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 N SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-4462
Mailing Address - Country:US
Mailing Address - Phone:317-541-2920
Mailing Address - Fax:
Practice Address - Street 1:3840 N SHERMAN DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-4462
Practice Address - Country:US
Practice Address - Phone:317-541-2920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2350-24-0013171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200503650Medicaid