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General NPI Number Information
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NPI Number | 1508221284
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Entity Type | Individual
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Provider Name | MARY SUE MOORE PMHNP
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Gender | Female
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Dates
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Enumeration Date | 12/22/2015
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Last Update Date | 02/03/2026
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Provider Practice Location Address
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Address Line | 401 CECIL G COSTIN SR BLVD
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City | PORT ST JOE
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State | FL
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Zip | 32456-1928
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Country | US
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Telephone | 850-229-1043
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Fax |
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Provider Business Mailing Address
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Address Line | 11523 SW MCCLELLAN FARM RD
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City | CLARKSVILLE
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State | FL
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Zip | 32430-3043
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Country | US
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Telephone | 850-899-3191
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Fax |
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN9162481
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License Number State | FL
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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 | APRN9162481
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License Number State | FL
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