Healthcare Provider Details

I. General information

NPI: 1053984500
Provider Name (Legal Business Name): NICOLLE MARIE MOORE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 DAKOTA DUNES BLVD STE D
DAKOTA DUNES SD
57049-5341
US

IV. Provider business mailing address

317 DAKOTA DUNES BLVD STE D
DAKOTA DUNES SD
57049-5341
US

V. Phone/Fax

Practice location:
  • Phone: 605-418-8409
  • Fax: 605-599-7105
Mailing address:
  • Phone: 605-418-8409
  • Fax: 605-599-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA164738
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: