Provider Demographics
NPI:1336571298
Name:MOORE, MELISSA (APRN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:HINDMAN
Mailing Address - State:KY
Mailing Address - Zip Code:41822-0849
Mailing Address - Country:US
Mailing Address - Phone:606-785-3164
Mailing Address - Fax:606-785-0107
Practice Address - Street 1:566 HIGHWAY 899
Practice Address - Street 2:
Practice Address - City:HINDMAN
Practice Address - State:KY
Practice Address - Zip Code:41822-8955
Practice Address - Country:US
Practice Address - Phone:606-785-3164
Practice Address - Fax:606-785-0107
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008199363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100302050Medicaid
KY7100302050Medicaid