1619392172 NPI number — MELISSA ROSE MOORE CNM, CNP, PMHNP-BC

Table of content: MELISSA ROSE MOORE CNM, CNP, PMHNP-BC (NPI 1619392172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619392172 NPI number — MELISSA ROSE MOORE CNM, CNP, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
MELISSA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM, CNP, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEMORIE
Provider Other First Name:
MELISSA
Provider Other Middle Name:
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:
1619392172
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 11TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87104-2105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-923-6043
Provider Business Mailing Address Fax Number:
505-727-4505

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 11TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87104-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-923-6043
Provider Business Practice Location Address Fax Number:
505-727-4505
Provider Enumeration Date:
02/20/2014

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: 163W00000X , with the licence number:  RN-78727 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163W00000X , with the licence number: 4704257647 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: 670 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 77534 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31902243 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".