Provider Demographics
NPI:1275824120
Name:MOORE, BRENDA KAY (DO)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 COLLEGE BLVD W
Mailing Address - Street 2:SUITE #2
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1068
Mailing Address - Country:US
Mailing Address - Phone:850-678-0443
Mailing Address - Fax:850-678-7999
Practice Address - Street 1:1003 COLLEGE BLVD W
Practice Address - Street 2:SUITE #2
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1068
Practice Address - Country:US
Practice Address - Phone:850-678-0443
Practice Address - Fax:850-678-7999
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP9912207Q00000X
FLOS12957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program