1205980844 NPI number — CHAQUITA M MOORE FNP

Table of content: CHAQUITA M MOORE FNP (NPI 1205980844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205980844 NPI number — CHAQUITA M MOORE FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
CHAQUITA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
CHAQUITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205980844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 FOX DEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31021-4361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-361-9621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 SPRING BRANCH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-0356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-274-8489
Provider Business Practice Location Address Fax Number:
478-275-0731
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN138492 NP , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN138492 NP . This is a "LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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