Provider Demographics
NPI:1649654203
Name:MOORER, DENITA RAYMONDE (ARNP)
Entity type:Individual
Prefix:
First Name:DENITA
Middle Name:RAYMONDE
Last Name:MOORER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43667
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-3667
Mailing Address - Country:US
Mailing Address - Phone:904-398-3760
Mailing Address - Fax:904-398-2480
Practice Address - Street 1:820 PRUDENTIAL DR STE 112
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8204
Practice Address - Country:US
Practice Address - Phone:904-396-5996
Practice Address - Fax:904-398-2480
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9344512363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIN PROCESSMedicaid
FLAWAITING FL MCROtherRAILROAD MEDICARE
FLIN PROCESSMedicare PIN