Provider Demographics
NPI:1871821165
Name:MOORE, JENNIFER (CRNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
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 2127
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-2127
Mailing Address - Country:US
Mailing Address - Phone:256-236-5631
Mailing Address - Fax:256-624-9388
Practice Address - Street 1:1010 CHRISTINE AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5782
Practice Address - Country:US
Practice Address - Phone:256-236-5631
Practice Address - Fax:256-624-9388
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-112453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL124615Medicaid
GARN171132OtherLICENSE NUMBER
AL1-112453OtherALABAMA LICENSE
AL511-11378OtherBCBS