Provider Demographics
NPI:1952688178
Name:MOORE, ELISA SPADARO (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:SPADARO
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2401 S BRENTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2301
Mailing Address - Country:US
Mailing Address - Phone:314-687-2663
Mailing Address - Fax:636-687-2740
Practice Address - Street 1:225 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2278
Practice Address - Country:US
Practice Address - Phone:636-230-5050
Practice Address - Fax:636-230-5057
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007007648163WP2201X
MO2011040127363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO146890010Medicare PIN