Provider Demographics
NPI:1023671963
Name:MOORE, NICHOLE LYNN (LPN)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-1552
Mailing Address - Country:US
Mailing Address - Phone:937-765-2229
Mailing Address - Fax:
Practice Address - Street 1:100 ELMWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-5402
Practice Address - Country:US
Practice Address - Phone:937-247-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH126503.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse