Healthcare Provider Details

I. General information

NPI: 1265071450
Provider Name (Legal Business Name): STACY LYNN MOORE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 TITAN DR
FLORENCE AL
35630-1197
US

IV. Provider business mailing address

156 TITAN DR
FLORENCE AL
35630-1197
US

V. Phone/Fax

Practice location:
  • Phone: 256-740-0690
  • Fax: 256-740-0694
Mailing address:
  • Phone: 256-740-0690
  • Fax: 256-740-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-092232
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: