Provider Demographics
NPI:1871826610
Name:MOORE, ELIZABETH JANE (PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:JANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2514 OAK PARK COURT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1282
Mailing Address - Country:US
Mailing Address - Phone:774-285-0822
Mailing Address - Fax:765-530-8099
Practice Address - Street 1:410 NORTH 10TH STREET
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-3116
Practice Address - Country:US
Practice Address - Phone:774-285-0822
Practice Address - Fax:765-530-8099
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005185A363LP0808X, 2084P0800X
IN71005185B2084P0800X
IN28087121A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201258280Medicaid
IN000000899248OtherANTHEM
IN259370048Medicare PIN