MEDICARE: NICOLE MOORE NP

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	363L00000X	Nurse Practitioner	4704230526	MI

General Provider Information

NPI Number	:	1558731075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MOORE NP

Provider Business Mailing Address
First Line	:	1014 SIXTH ST STE 101
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2398
Country	:	US
Telephone Number	:	231-421-6921
Fax Number	:	231-421-7852

Provider Business Practice Location Address
First Line	:	1014 SIXTH ST STE 101
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2398
Country	:	US
Telephone Number	:	231-421-6921
Fax Number	:	231-421-7852

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

Provider Enumeration Date	:	09/26/2015
Last Update Date	:	09/26/2015

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Directions to “ NICOLE MOORE NP” Practice Location

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