Provider Demographics
NPI:1750890042
Name:MOORE, REBECCA SUE (FNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:321 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1013
Practice Address - Country:US
Practice Address - Phone:989-466-3332
Practice Address - Fax:989-466-6805
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704336548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21294Other21294