Provider Demographics
NPI:1023395431
Name:MOORE, REBECCA AYNE (CNM)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:AYNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-2514
Mailing Address - Fax:
Practice Address - Street 1:231 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3807
Practice Address - Country:US
Practice Address - Phone:513-318-1188
Practice Address - Fax:513-318-1189
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA12727NM367A00000X
IN09000293A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109990Medicaid
IN259370200OtherMEDICARE
OHH381060Medicare PIN