Healthcare Provider Details

I. General information

NPI: 1184986937
Provider Name (Legal Business Name): MRS. NICOLE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 01/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 EXECUTIVE DR SUITE LL 105/108
PLAINVIEW NY
11803-1718
US

IV. Provider business mailing address

4212 213TH ST APARTMENT 2
BAYSIDE NY
11361-2853
US

V. Phone/Fax

Practice location:
  • Phone: 516-576-2040
  • Fax: 516-576-2131
Mailing address:
  • Phone: 516-382-2688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1184159
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: