=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548242670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOLEEN COMER MOORE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 BONNIE BROOK RD
-----------------------------------------------------
City | ABERDEEN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28315-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-716-0099
-----------------------------------------------------
Fax | 910-405-1359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 BONNIE BROOK RD
-----------------------------------------------------
City | ABERDEEN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28315-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-716-0099
-----------------------------------------------------
Fax | 910-405-1359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 22951
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 201093
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------