Healthcare Provider Details

I. General information

NPI: 1932019197
Provider Name (Legal Business Name): BRYANNA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 SAINT ROSEA RD
WILMINGTON NC
28405-3387
US

IV. Provider business mailing address

323 SAINT ROSEA RD
WILMINGTON NC
28405-3387
US

V. Phone/Fax

Practice location:
  • Phone: 314-478-2052
  • Fax:
Mailing address:
  • Phone: 314-478-2052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5025439
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: