Healthcare Provider Details

I. General information

NPI: 1568516425
Provider Name (Legal Business Name): GERALDINE L MOORE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GERALDINE L DUNSTON

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 STATE BRIDGE RD
DULUTH GA
30097-8220
US

IV. Provider business mailing address

5609 MOUNTAIN VIEW PT
STONE MOUNTAIN GA
30087-6022
US

V. Phone/Fax

Practice location:
  • Phone: 678-495-0162
  • Fax: 678-495-0163
Mailing address:
  • Phone: 770-469-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number086734
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: