Provider Demographics
NPI:1164689071
Name:MOORE, WHITNEY W (NP-C)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:W
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14213 COOK RD BLDG A
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-9719
Mailing Address - Country:US
Mailing Address - Phone:228-575-2545
Mailing Address - Fax:228-872-8029
Practice Address - Street 1:11700 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565-8309
Practice Address - Country:US
Practice Address - Phone:228-826-1482
Practice Address - Fax:228-826-5924
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866158363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07351098Medicaid
MS07351098Medicaid