Provider Demographics
NPI:1679209472
Name:MOORE, KATIE C (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:C
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 1:2996 E HIGHWAY 501
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9532
Mailing Address - Country:US
Mailing Address - Phone:843-347-2613
Mailing Address - Fax:
Practice Address - Street 1:2996 E HIGHWAY 501
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9532
Practice Address - Country:US
Practice Address - Phone:843-347-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26350363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily