Healthcare Provider Details

I. General information

NPI: 1568392595
Provider Name (Legal Business Name): NIKKITA PATRICE MOORE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5210 BOX 230 RAF LAKENHEATH
APO AE
09461
US

IV. Provider business mailing address

48TH MDG/RAF LAKENHEATH
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 770-403-3461
  • Fax:
Mailing address:
  • Phone: 770-403-3461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1057413
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: