Provider Demographics
NPI:1013757020
Name:MOORE, MELODY ANN (AGACNP)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CLUBHOUSE AVE APT H
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3232
Mailing Address - Country:US
Mailing Address - Phone:310-363-5295
Mailing Address - Fax:
Practice Address - Street 1:501 E HARDY ST STE 160
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4033
Practice Address - Country:US
Practice Address - Phone:310-295-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030265363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care