Provider Demographics
NPI:1780413609
Name:BLAIR-MOXAM, SHARON (APRN)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BLAIR-MOXAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5164 VIZCAYA ST
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-9602
Mailing Address - Country:US
Mailing Address - Phone:754-368-5488
Mailing Address - Fax:
Practice Address - Street 1:5164 VIZCAYA ST
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-9602
Practice Address - Country:US
Practice Address - Phone:754-368-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034079363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health