Provider Demographics
NPI:1013048289
Name:MOORE, EMILY THERESA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:THERESA
Last Name:MOORE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7096 BIG FOOT RD
Mailing Address - Street 2:
Mailing Address - City:MELBA
Mailing Address - State:ID
Mailing Address - Zip Code:83641-5074
Mailing Address - Country:US
Mailing Address - Phone:208-495-1500
Mailing Address - Fax:
Practice Address - Street 1:707 N ARMSTRONG PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0825
Practice Address - Country:US
Practice Address - Phone:208-327-7400
Practice Address - Fax:208-327-8579
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP112A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner