Provider Demographics
NPI:1225434772
Name:MOORE, TONYA (APN)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
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Mailing Address - Street 1:420 NE GLEN OAK AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3112
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:834 N SEMINARY ST STE 501
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-0501
Practice Address - Country:US
Practice Address - Phone:309-343-4114
Practice Address - Fax:309-676-8455
Is Sole Proprietor?:No
Enumeration Date:2014-11-11
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209012046363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209012046Medicaid