MEDICARE: CASEY MOORE APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11018653	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033867759
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY MOORE APRN

Provider Business Mailing Address
First Line	:	634 DYAL ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-3916
Country	:	US
Telephone Number	:	904-446-7854
Fax Number	:

Provider Business Practice Location Address
First Line	:	1697 KINGS RD STE 1
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-6169
Country	:	US
Telephone Number	:	904-478-5483
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	05/21/2022

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Directions to “ CASEY MOORE APRN” Practice Location

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