Healthcare Provider Details

I. General information

NPI: 1659081297
Provider Name (Legal Business Name): HANNAH GRACE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HANNAH GRACE MOORE

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 W BROADWAY
FULTON NY
13069-1571
US

IV. Provider business mailing address

100 METROPOLITAN PARK DR STE 100
LIVERPOOL NY
13088-7112
US

V. Phone/Fax

Practice location:
  • Phone: 315-297-4700
  • Fax: 315-218-5898
Mailing address:
  • Phone: 315-870-9369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number350677
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: