Provider Demographics
NPI:1720430580
Name:MOORE, NICOLE KAY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N.
Other - Middle Name:KAY
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8118 GOOD LUCK RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3574
Practice Address - Country:US
Practice Address - Phone:301-324-4968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.331366390200000X
MDR224991367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program