Provider Demographics
NPI:1902282809
Name:MOORE, JOHANNA (FNP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:TOPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4110 BRIARGATE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7835
Mailing Address - Country:US
Mailing Address - Phone:719-632-7669
Mailing Address - Fax:
Practice Address - Street 1:4110 BRIARGATE PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7835
Practice Address - Country:US
Practice Address - Phone:719-632-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0991887363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0991887OtherFNP LICENSE