Healthcare Provider Details

I. General information

NPI: 1720430580
Provider Name (Legal Business Name): NICOLE KAY MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: N. KAY MOORE

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

V. Phone/Fax

Practice location:
  • Phone: 301-324-4968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRN.331366
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR224991
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: