MEDICARE: NICOLE E. MOORE

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	163W00000X	Registered Nurse	L1-0048126	DE
2	207Q00000X	Family Medicine Physician	LG-0011888	DE

General Provider Information

NPI Number	:	1992457147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE E. MOORE

Provider Business Mailing Address
First Line	:	424 MULBERRY ST
Second Line	:
City	:	MILTON
State	:	DE
Zip	:	19968-1628
Country	:	US
Telephone Number	:	302-684-0561
Fax Number	:

Provider Business Practice Location Address
First Line	:	424 MULBERRY ST
Second Line	:
City	:	MILTON
State	:	DE
Zip	:	19968-1628
Country	:	US
Telephone Number	:	302-684-0561
Fax Number	:

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

Provider Enumeration Date	:	01/19/2022
Last Update Date	:	02/07/2022

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Directions to “ NICOLE E. MOORE ” Practice Location

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