MEDICARE: CHAQUITA M MOORE FNP

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	RN138492 NP	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RN138492 NP	OTHER	GA	LICENSE

General Provider Information

NPI Number	:	1205980844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAQUITA M MOORE FNP

Provider Business Mailing Address
First Line	:	205 FOX DEN CT
Second Line	:
City	:	DUBLIN
State	:	GA
Zip	:	31021-4361
Country	:	US
Telephone Number	:	478-361-9621
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 SPRING BRANCH DR
Second Line	:
City	:	DUBLIN
State	:	GA
Zip	:	31021-0356
Country	:	US
Telephone Number	:	478-274-8489
Fax Number	:	478-275-0731

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	10/31/2017

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