MEDICARE: NICOLE MOORE OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OT 15543	FL

General Provider Information

NPI Number	:	1255741294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MOORE OTR/L

Provider Business Mailing Address
First Line	:	4615 EXPLORER DR APT 207
Second Line	:
City	:	WEST MELBOURNE
State	:	FL
Zip	:	32904-9191
Country	:	US
Telephone Number	:	607-267-2706
Fax Number	:

Provider Business Practice Location Address
First Line	:	409 E OAKLAND AVE UNIT B
Second Line	:
City	:	OAKLAND
State	:	FL
Zip	:	34787-3070
Country	:	US
Telephone Number	:	407-654-5455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	04/29/2014

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Directions to “ NICOLE MOORE OTR/L” Practice Location

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