Provider Demographics
NPI:1770771586
Name:MOORE, MELISSA D (FNP-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4215
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2600
Practice Address - Fax:417-820-2100
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000163207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO836673268Medicare PIN
MO836673230Medicare PIN