Healthcare Provider Details

I. General information

NPI: 1730552837
Provider Name (Legal Business Name): JANICE MOORE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 CAROLINA EXCHANGE DR
MYRTLE BEACH SC
29579-4220
US

IV. Provider business mailing address

PO BOX 547
LITTLE RIVER SC
29566-0547
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-8000
  • Fax: 843-663-8158
Mailing address:
  • Phone: 843-663-8000
  • Fax: 843-663-8158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19726
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: