Healthcare Provider Details

I. General information

NPI: 1184062556
Provider Name (Legal Business Name): SCOTT EMORY MOORE APRN-CNP, AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 ROADOAN RD
BROOKLYN OH
44144-2745
US

IV. Provider business mailing address

4437 ROADOAN RD
BROOKLYN OH
44144-2745
US

V. Phone/Fax

Practice location:
  • Phone: 864-430-5093
  • Fax:
Mailing address:
  • Phone: 864-430-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.0041841
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: