Provider Demographics
NPI:1912911421
Name:MOORE, MARY SARA (PSYCH NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SARA
Last Name:MOORE
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Gender:F
Credentials:PSYCH NP
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Mailing Address - Street 1:126 MISSOURI AVE
Mailing Address - Street 2:MCXP - CCS - CR
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-8952
Mailing Address - Country:US
Mailing Address - Phone:573-596-0417
Mailing Address - Fax:573-596-0524
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:MCXP - CCS - CR
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-0417
Practice Address - Fax:573-596-0524
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO152094363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health