Provider Demographics
NPI:1255984043
Name:MOORE, MICHELLE JEAN (APRN)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EMPIRE LN
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-3069
Mailing Address - Country:US
Mailing Address - Phone:203-994-6720
Mailing Address - Fax:
Practice Address - Street 1:95 LOCUST AVENUE 1ST FLOOR ONCOLOGY
Practice Address - Street 2:STROOCK BUILDING
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-739-7029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-20
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8254OtherLICENSE