1700494374 NPI number — VANESSA LYNN MOE NP

Table of content: VANESSA LYNN MOE NP (NPI 1700494374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700494374 NPI number — VANESSA LYNN MOE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOE
Provider First Name:
VANESSA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1700494374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3003 N CENTRAL AVE STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-2929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-685-6000
Provider Business Mailing Address Fax Number:
602-302-7925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8804 N. 23RD AVENUE
Provider Second Line Business Practice Location Address:
BLDG A, STE A01 & A02
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85021-4160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-685-6000
Provider Business Practice Location Address Fax Number:
602-216-7040
Provider Enumeration Date:
07/20/2020

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: 363LP0808X , with the licence number:  244749 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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