Healthcare Provider Details

I. General information

NPI: 1720018211
Provider Name (Legal Business Name): JENNIFER L MOES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 MADISON AVE W
IMMOKALEE FL
34142-2200
US

IV. Provider business mailing address

6360 TECHSTER BLVD
FORT MYERS FL
33966-4805
US

V. Phone/Fax

Practice location:
  • Phone: 239-658-3707
  • Fax:
Mailing address:
  • Phone: 239-223-2751
  • Fax: 239-561-2933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN9461847
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9461847
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: