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General NPI Number Information
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NPI Number | 1881064319
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Entity Type | Organization
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Legal Business Name | NICOLE R. MOFFETT OD PA
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Dates
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Enumeration Date | 09/27/2015
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Last Update Date | 09/27/2015
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Provider Practice Location Address
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Address Line | 2365 CRAIN HWY
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City | WALDORF
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State | MD
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Zip | 20601-3167
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Country | US
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Telephone | 301-932-9408
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 451
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City | CHELTENHAM
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State | MD
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Zip | 20623-0451
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. NICOLE RENEE MOFFETT
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Credential | O.D.
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Telephone | 301-627-5090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TA 1223
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License Number State | MD
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