Provider Demographics
NPI:1962852988
Name:MOORE, LONNIE L (NP)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-1832
Mailing Address - Country:US
Mailing Address - Phone:166-232-6350
Mailing Address - Fax:662-326-3502
Practice Address - Street 1:1022 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1832
Practice Address - Country:US
Practice Address - Phone:662-326-3500
Practice Address - Fax:901-756-5564
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily