1730240326 NPI number — MRS. LISA S MOORE ARNP, DBP

Table of content: MRS. LISA S MOORE ARNP, DBP (NPI 1730240326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730240326 NPI number — MRS. LISA S MOORE ARNP, DBP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
LISA
Provider Middle Name:
S
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP, DBP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730240326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
816 SE OCEAN BLVD
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34994-2428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-220-0033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PALMETTO FAMILY HEALTH CARE
Provider Second Line Business Practice Location Address:
4821 U.S. HWY 98, SUITE 104
Provider Business Practice Location Address City Name:
SANTA ROSA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-622-2055
Provider Business Practice Location Address Fax Number:
580-622-2053
Provider Enumeration Date:
12/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP9166216 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)