Healthcare Provider Details

I. General information

NPI: 1770068942
Provider Name (Legal Business Name): OLIVER MOORE DNP, APN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 BROAD ST STE 606
NEWARK NJ
07102-4537
US

IV. Provider business mailing address

532 MARLTON PIKE W # 407
MARLTON NJ
08053-2075
US

V. Phone/Fax

Practice location:
  • Phone: 201-822-1161
  • Fax: 877-485-8918
Mailing address:
  • Phone: 323-853-8019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00872800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: