Basic Information
| Provider Information | |||||||||
| NPI: | 1407086614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MACGILLIS | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2110 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | ROCKY HILL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060672313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602583470 | ||||||||
| FaxNumber: | 8605716800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 SILAS DEANE HWY | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602583477 | ||||||||
| FaxNumber: | 8605716802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2009 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 004185 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 004185 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 004185 | 01 | CT | LICENSE | OTHER |