Basic Information
| Provider Information | |||||||||
| NPI: | 1619392172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEMORIE | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4705 MONTGOMERY BLVD NE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871091226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057274500 | ||||||||
| FaxNumber: | 5057274505 | ||||||||
| Practice Location | |||||||||
| Address1: | 4705 MONTGOMERY BLVD NE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871091226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057274500 | ||||||||
| FaxNumber: | 5057274505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2014 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-78727 | NM | N | Nursing Service Providers | Registered Nurse | 163W00000X | 4704257647 | MI | N | Nursing Service Providers | Registered Nurse | 367A00000X | 670 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 31902243 | 05 | NM | MEDICAID |