Healthcare Provider Details

I. General information

NPI: 1043785512
Provider Name (Legal Business Name): NIKKI MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKI STEPHENS

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 TRAILWOOD DR
BOARDMAN OH
44512-5008
US

IV. Provider business mailing address

901 TRAILWOOD DR
BOARDMAN OH
44512-5008
US

V. Phone/Fax

Practice location:
  • Phone: 234-287-6544
  • Fax: 330-259-9721
Mailing address:
  • Phone: 234-287-6544
  • Fax: 330-259-9721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.023742
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: