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General NPI Number Information
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NPI Number | 1780021436
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Entity Type | Individual
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Provider Name | NICOLE LYNN MOORE CRNP
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Gender | Female
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 02/09/2024
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Provider Practice Location Address
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Address Line | 4475 SAN JUAN AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32210-3357
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Country | US
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Telephone | 615-425-4258
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Fax |
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Provider Business Mailing Address
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Address Line | 1512 TURTLE BAY CV
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-6506
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Country | US
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Telephone | 720-707-9033
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R179324
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 0993089
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APRN11009416
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License Number State | FL
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