Basic Information
| Provider Information | |||||||||
| NPI: | 1033141155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | C.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1550 E COUNTY LINE RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462271000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174972300 | ||||||||
| FaxNumber: | 3174972502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | 71000750A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000042207 | 01 | IN | ANTHEM BCBS | OTHER | 100473980 | 05 | IN | MEDICAID | 2439492000 | 01 | KY | PASSPORT ADVANTAGE | OTHER | 709911P | 01 | IN | SIHO | OTHER | 500012166 | 01 | MEDICARE RAILROAD | OTHER | 1161025 | 01 | KY | PASSPORT KY MEDICAID | OTHER | 5012042 | 01 | AETNA | OTHER | 78007887 | 05 | KY | MEDICAID |