Provider Demographics
NPI:1255010039
Name:MOORE, AMANDA (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3522 HIGHFIELD CT APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-1667
Mailing Address - Country:US
Mailing Address - Phone:757-768-0837
Mailing Address - Fax:
Practice Address - Street 1:3640 N BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-6375
Practice Address - Country:US
Practice Address - Phone:463-777-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27079375C164W00000X
IN27079375A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse