Basic Information
| Provider Information | |||||||||
| NPI: | 1366746257 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | KAREN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5515 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491279670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694299644 | ||||||||
| FaxNumber: | 2694294002 | ||||||||
| Practice Location | |||||||||
| Address1: | 5515 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491279670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694299644 | ||||||||
| FaxNumber: | 2694294002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2011 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704282019 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1366746257 | 05 | MI | MEDICAID |