Provider Demographics
NPI:1912143397
Name:MOORE, LOLA DIANE (RN, MN, PMHNP)
Entity Type:Individual
Prefix:MS
First Name:LOLA
Middle Name:DIANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN, MN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 AMANDA CT
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-3467
Mailing Address - Country:US
Mailing Address - Phone:503-650-4431
Mailing Address - Fax:
Practice Address - Street 1:17714 SE ADDIE ST APT B
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6148
Practice Address - Country:US
Practice Address - Phone:503-659-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR095000161RN163W00000X
OR200950098NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid
ORR155859Medicare PIN