Healthcare Provider Details

I. General information

NPI: 1962520841
Provider Name (Legal Business Name): MARY THURSTON MOYNAHAN FNP, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 EXETER STREET
MANTEO NC
27954-1000
US

IV. Provider business mailing address

189 HIGH DUNE LOOP
KITTY HAWK NC
27949-3710
US

V. Phone/Fax

Practice location:
  • Phone: 252-475-5007
  • Fax:
Mailing address:
  • Phone: 252-261-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201043
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: