Basic Information
| Provider Information | |||||||||
| NPI: | 1700494374 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOE | ||||||||
| FirstName: | VANESSA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6023027925 | ||||||||
| Practice Location | |||||||||
| Address1: | 8804 N. 23RD AVENUE | ||||||||
| Address2: | BLDG A, STE A01 & A02 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850214160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026856000 | ||||||||
| FaxNumber: | 6022167040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 244749 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.