Provider Demographics
NPI:1669023537
Name:MOORE, JOELLEN
Entity type:Individual
Prefix:MRS
First Name:JOELLEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 ANDERSON WAY
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-7627
Mailing Address - Country:US
Mailing Address - Phone:479-883-3241
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114
Practice Address - Country:US
Practice Address - Phone:501-257-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider