Provider Demographics
NPI:1770593212
Name:MOORE, SUSAN U (CFNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:U
Last Name:MOORE
Suffix:
Gender:
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382
Mailing Address - Country:US
Mailing Address - Phone:276-228-6499
Mailing Address - Fax:276-228-6145
Practice Address - Street 1:1785 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1437
Practice Address - Country:US
Practice Address - Phone:276-228-6499
Practice Address - Fax:276-228-6665
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24166578363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ78986Medicare UPIN