Provider Demographics
NPI:1164528816
Name:MOORE, VIRGINIA GAIL (PHD, APRN, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:GAIL
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD, APRN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10549 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-2415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10549 115TH AVE
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-2415
Practice Address - Country:US
Practice Address - Phone:941-204-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60895080363LP0808X
FLARNP 9275839363LP0808X
OR202002782NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000487000Medicaid