1093055188 NPI number — MS. MISTY JANE MOORE CRNA

Table of content: MS. MISTY JANE MOORE CRNA (NPI 1093055188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093055188 NPI number — MS. MISTY JANE MOORE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
MISTY
Provider Middle Name:
JANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FINNEY
Provider Other First Name:
MISTY
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093055188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
429 EVENING SHADOWS TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLY LAKE RANCH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75765-6346
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-832-9566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6606 LBJ FWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75240-6524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-715-5000
Provider Business Practice Location Address Fax Number:
972-715-9976
Provider Enumeration Date:
02/26/2013

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: 367500000X , with the licence number:  RN3347012 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP145429 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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