Healthcare Provider Details

I. General information

NPI: 1194252650
Provider Name (Legal Business Name): HANNAH MOORE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4649 ROBINSON RD
VALDOSTA GA
31605-5486
US

IV. Provider business mailing address

4649 ROBINSON RD
VALDOSTA GA
31605-5486
US

V. Phone/Fax

Practice location:
  • Phone: 229-425-9263
  • Fax: 229-425-9263
Mailing address:
  • Phone: 229-425-9263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN222613
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN222613
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: