1275684268 NPI number — STACEY J MOORE ARNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275684268 NPI number — STACEY J MOORE ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
STACEY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1275684268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41017-0510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-341-5550
Provider Business Mailing Address Fax Number:
859-344-3782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 DIXIE HWY
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
FT WRIGHT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41011-2792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-341-5550
Provider Business Practice Location Address Fax Number:
859-344-3782
Provider Enumeration Date:
01/16/2007

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:  3808P , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WW0101X , with the licence number: 1086649 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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