Provider Demographics
NPI:1245890144
Name:MOORE, NICOLE JONES (NP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JONES
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 RIVIERA CIR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8682
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 JOHN EVERETT RD
Practice Address - Street 2:
Practice Address - City:MOSELLE
Practice Address - State:MS
Practice Address - Zip Code:39459-9771
Practice Address - Country:US
Practice Address - Phone:251-753-9148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily