Provider Demographics
NPI:1578043972
Name:MOORE, MONICA CORNWALL (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:CORNWALL
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8239 N MAYFIELD LN
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-2203
Mailing Address - Country:US
Mailing Address - Phone:804-513-6012
Mailing Address - Fax:
Practice Address - Street 1:8200 MEADOWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2337
Practice Address - Country:US
Practice Address - Phone:804-442-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1225263940Medicaid