Healthcare Provider Details

I. General information

NPI: 1407042930
Provider Name (Legal Business Name): TINA MARIE MORAN ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2565 N TOLEDO BLADE BLVD
NORTH PORT FL
34289-9306
US

IV. Provider business mailing address

2565 N TOLEDO BLADE BLVD
NORTH PORT FL
34289-9306
US

V. Phone/Fax

Practice location:
  • Phone: 941-770-6393
  • Fax: 941-237-5737
Mailing address:
  • Phone: 941-770-6393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11026700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: