Provider Demographics
NPI:1508221284
Name:MOORE, MARY SUE (APRN, DNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11523 SW MCCLELLAN FARM RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32430-3043
Mailing Address - Country:US
Mailing Address - Phone:850-899-3191
Mailing Address - Fax:
Practice Address - Street 1:401 CECIL G COSTIN SR BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1928
Practice Address - Country:US
Practice Address - Phone:850-229-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9162481363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily