Provider Demographics
NPI:1801319231
Name:MOORE, COURTNEY L (NP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 E CRICKET KNL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8103
Mailing Address - Country:US
Mailing Address - Phone:812-345-7268
Mailing Address - Fax:317-674-0060
Practice Address - Street 1:4325 E CRICKET KNL
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8103
Practice Address - Country:US
Practice Address - Phone:812-345-7268
Practice Address - Fax:317-674-0060
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007248A363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner