Provider Demographics
NPI:1649651639
Name:MOORE, COURTNEY JEAN (APRN, CNM)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3706
Mailing Address - Country:US
Mailing Address - Phone:612-545-5311
Mailing Address - Fax:612-224-9622
Practice Address - Street 1:2635 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1270
Practice Address - Country:US
Practice Address - Phone:651-254-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNM 0268367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife