Basic Information
| Provider Information | |||||||||
| NPI: | 1316561202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6267 40TH STREET CT E | ||||||||
| Address2: | |||||||||
| City: | FIFE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984242344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196381209 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 S PARKER ST STE 2800 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532400530 | ||||||||
| FaxNumber: | 4805463134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2020 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 61083112 | WA | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN61083112 | WA | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 61114903 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP61114903 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | NP95019703 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.