Basic Information
| Provider Information | |||||||||
| NPI: | 1396276416 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DORENE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST FL 7 | ||||||||
| Address2: | HCR MANORCARE MEDICAL SERVICES / HEARTLAND CARE PARTNER | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004271902 | ||||||||
| FaxNumber: | 4195312664 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 S MARKET ST | ||||||||
| Address2: | HEARTLAND CARE PARTNERS | ||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170222422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004271902 | ||||||||
| FaxNumber: | 4195312664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2017 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP017095 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.