Provider Demographics
NPI:1346828449
Name:MOORE, CAROL A (NP)
Entity Type:Individual
Prefix:MISS
First Name:CAROL
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25706 CRAFT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3010
Mailing Address - Country:US
Mailing Address - Phone:718-730-0529
Mailing Address - Fax:
Practice Address - Street 1:25706 CRAFT AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3010
Practice Address - Country:US
Practice Address - Phone:718-730-0529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF309373-01363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health