Individual
ILLARIA C MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP-C
Contact information
Practice address
11050 MONTANA AVE, BOISE, ID 83713-5049
(208) 954-6783
Mailing address
11050 MONTANA AVE, BOISE, ID 83713-5049
(208) 954-6783
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
NP-1326A
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
AG0613029
NURSE PRACTITIONER CERTIFICATION
—
01
—
NP-1326A
LICENSE NUMBER
ID
Enumeration date
08/31/2013
Last updated
08/31/2013
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