Healthcare Provider Details

I. General information

NPI: 1407345382
Provider Name (Legal Business Name): NIKKI MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2018
Last Update Date: 05/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 HIGHWAY 71 N
ALMA AR
72921-5114
US

IV. Provider business mailing address

1119 S FRANKFORT AVE
RUSSELLVILLE AR
72801-6948
US

V. Phone/Fax

Practice location:
  • Phone: 479-632-6688
  • Fax:
Mailing address:
  • Phone: 479-280-3086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA005616
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: