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General NPI Number Information
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NPI Number | 1316561202
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Entity Type | Individual
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Provider Name | THERESA LYNN MOORE PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 06/05/2020
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Last Update Date | 01/15/2026
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Provider Practice Location Address
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Address Line | 1615 POLO RD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-3831
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Country | US
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Telephone | 336-722-7266
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Fax | 336-201-0538
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Provider Business Mailing Address
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Address Line | 1615 POLO RD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-3831
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Country | US
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Telephone | 336-722-7266
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Fax | 336-201-0538
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 5022767
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | NP95019703
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License Number State | CA
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