Healthcare Provider Details

I. General information

NPI: 1326575069
Provider Name (Legal Business Name): DANIEL MOORE NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BROOKWAY BLVD
BROOKHAVEN MS
39601-2644
US

IV. Provider business mailing address

940 BROOKWAY BLVD
BROOKHAVEN MS
39601-2644
US

V. Phone/Fax

Practice location:
  • Phone: 601-823-5000
  • Fax: 601-823-4140
Mailing address:
  • Phone: 601-823-5000
  • Fax: 601-823-4140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number892107
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902196
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: