Provider Demographics
NPI:1255525770
Name:MOORE, VANESSA L (FNP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:L
Other - Last Name:KINDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:250 N SHADELAND AVE
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:
Mailing Address - Fax:
Practice Address - Street 1:2900 W 16TH STREET
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47446
Practice Address - Country:US
Practice Address - Phone:812-275-5993
Practice Address - Fax:812-275-1352
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28148177A163W00000X
IN71002478363LF0000X
IN71002478A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN090540102OtherMEDICARE PTAN
IN237042323OtherCOMMERCIAL
IN200873510Medicaid