Healthcare Provider Details

I. General information

NPI: 1184173247
Provider Name (Legal Business Name): MICHELLE DENISE MOORE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516B LINCOLN RD
COLUMBUS MS
39705-2226
US

IV. Provider business mailing address

1700 CAL KOLOLA RD
CALEDONIA MS
39740-9460
US

V. Phone/Fax

Practice location:
  • Phone: 662-241-7177
  • Fax: 662-241-7176
Mailing address:
  • Phone: 662-574-3894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901781
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: