Healthcare Provider Details

I. General information

NPI: 1134122559
Provider Name (Legal Business Name): CAROLYN M MOFFA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CENTURIAN DR STE 200
NEWARK DE
19713-2137
US

IV. Provider business mailing address

4755 OGLETOWN STANTON ROAD SUITE 1E50
NEWARK DE
19718
US

V. Phone/Fax

Practice location:
  • Phone: 302-366-8600
  • Fax: 302-366-5646
Mailing address:
  • Phone: 302-733-1507
  • Fax: 302-733-4998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0000147
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: