Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | RN089230 | AZ |
NPI | 1174770853 |
---|---|
Provider Name | Ms. Susan Moore |
First Address | Flagstaff, AZ 86001-3118 |
Second Address | Flagstaff, AZ 86001-3118 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2008 |
Last Update Date | 19/11/2009 |