Provider Demographics
NPI:1013099068
Name:MOORE, ANGELO DEWITT (FNP)
Entity Type:Individual
Prefix:MR
First Name:ANGELO
Middle Name:DEWITT
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:21 MILLENNIUM LOOP
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-4337
Mailing Address - Country:US
Mailing Address - Phone:718-630-4186
Mailing Address - Fax:
Practice Address - Street 1:1075 STEPHENSON AVE
Practice Address - Street 2:PATTERSON ARMY HEALTH CLINIC
Practice Address - City:FORT MONMOUTH
Practice Address - State:NJ
Practice Address - Zip Code:07703-5000
Practice Address - Country:US
Practice Address - Phone:732-532-0182
Practice Address - Fax:732-532-0194
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138235163W00000X
TX648115363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily