Provider Demographics
NPI:1942816061
Name:MOORE, COURTNEY D (APRN)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
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 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-272-5052
Mailing Address - Fax:502-629-6217
Practice Address - Street 1:676 S FLOYD ST STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1840
Practice Address - Country:US
Practice Address - Phone:502-629-4440
Practice Address - Fax:502-629-4445
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014882363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3014882OtherLICENSE
KY7100748690Medicaid
IN71011795AOtherLICENSE