Provider Demographics
NPI:1013269422
Name:MOORE, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 PEACH ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9498
Mailing Address - Country:US
Mailing Address - Phone:336-543-4381
Mailing Address - Fax:
Practice Address - Street 1:3511 W MARKET ST
Practice Address - Street 2:STE. B
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-4443
Practice Address - Country:US
Practice Address - Phone:336-294-3338
Practice Address - Fax:336-294-6696
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300082KMedicaid