Provider Demographics
NPI:1205980844
Name:MOORE, CHAQUITA M (FNP)
Entity type:Individual
Prefix:
First Name:CHAQUITA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CHAQUITA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:205 FOX DEN CT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-4361
Mailing Address - Country:US
Mailing Address - Phone:478-361-9621
Mailing Address - Fax:
Practice Address - Street 1:160 SPRING BRANCH DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-0356
Practice Address - Country:US
Practice Address - Phone:478-274-8489
Practice Address - Fax:478-275-0731
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN138492 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN138492 NPOtherLICENSE