Provider Demographics
NPI:1003943796
Name:MOORE, MARY JANE (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 S SHADES CREST RD
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35022
Mailing Address - Country:US
Mailing Address - Phone:205-481-3566
Mailing Address - Fax:
Practice Address - Street 1:700 19TH ST S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1927
Practice Address - Country:US
Practice Address - Phone:205-933-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-026106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily