Healthcare Provider Details

I. General information

NPI: 1619415361
Provider Name (Legal Business Name): PAMELA SUSAN MOORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA SUSAN GRAY ARNP

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 W NEWBERRY RD
GAINESVILLE FL
32607-2245
US

IV. Provider business mailing address

4500 W NEWBERRY RD
GAINESVILLE FL
32607-2245
US

V. Phone/Fax

Practice location:
  • Phone: 352-336-6000
  • Fax:
Mailing address:
  • Phone: 352-336-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9348211
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN9348211
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: