Healthcare Provider Details

I. General information

NPI: 1962852988
Provider Name (Legal Business Name): LONNIE L MOORE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 MARTIN LUTHER KING DR
MARKS MS
38646-1832
US

IV. Provider business mailing address

1022 MARTIN LUTHER KING DR
MARKS MS
38646-1832
US

V. Phone/Fax

Practice location:
  • Phone: 662-326-3500
  • Fax: 901-756-5564
Mailing address:
  • Phone: 166-232-6350
  • Fax: 662-326-3502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901567
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: