Provider Demographics
NPI:1780021436
Name:MOORE, NICOLE LYNN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:1512 TURTLE BAY CV
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6506
Mailing Address - Country:US
Mailing Address - Phone:720-707-9033
Mailing Address - Fax:
Practice Address - Street 1:4475 SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3357
Practice Address - Country:US
Practice Address - Phone:615-425-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR179324363LF0000X
CO0993089363LF0000X
FLAPRN11009416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily