Basic Information
| Provider Information | |||||||||
| NPI: | 1386164630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | KRUGER | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 315 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 HIGHWAY 16 E | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390514222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012671406 | ||||||||
| FaxNumber: | 6012671469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2017 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R901923 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.