Provider Demographics
NPI:1750348546
Name:MOORE, LAVONNE M (RNC CNM)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:RNC CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 PENN AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55441
Mailing Address - Country:US
Mailing Address - Phone:612-543-2500
Mailing Address - Fax:612-302-4870
Practice Address - Street 1:1313 PENN AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55441
Practice Address - Country:US
Practice Address - Phone:612-543-2500
Practice Address - Fax:612-302-4870
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1138272363L00000X
MNR113827-2367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN702615300Medicaid
MN702615300Medicaid
500002868Medicare ID - Type Unspecified