Healthcare Provider Details

I. General information

NPI: 1750685558
Provider Name (Legal Business Name): MICHELE MARIE MOORE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W CRISER RD
FRONT ROYAL VA
22630-2360
US

IV. Provider business mailing address

209 W CRISER RD
FRONT ROYAL VA
22630-2360
US

V. Phone/Fax

Practice location:
  • Phone: 540-636-4250
  • Fax: 540-636-7171
Mailing address:
  • Phone: 540-636-4250
  • Fax: 540-636-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0001138275
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024169056
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: