Basic Information
| Provider Information | |||||||||
| NPI: | 1871707547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MEREDITH | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PMHNP, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970180095 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 58646 MCNULTY WAY | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970516210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | 5033975373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | OR | X | Nursing Service Providers | Registered Nurse | 363LP0808X | OR | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 123190 | 05 | OR | MEDICAID |