Healthcare Provider Details

I. General information

NPI: 1508221284
Provider Name (Legal Business Name): MARY SUE MOORE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 CECIL G COSTIN SR BLVD
PORT ST JOE FL
32456-1928
US

IV. Provider business mailing address

11523 SW MCCLELLAN FARM RD
CLARKSVILLE FL
32430-3043
US

V. Phone/Fax

Practice location:
  • Phone: 850-229-1043
  • Fax:
Mailing address:
  • Phone: 850-899-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9162481
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9162481
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN9162481
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: