Provider Demographics
NPI:1104513589
Name:MOORE, OLIVIA NICOLE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:NICOLE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-5603
Mailing Address - Fax:
Practice Address - Street 1:1333 TAYLOR ST STE 6F
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2953
Practice Address - Country:US
Practice Address - Phone:803-296-3273
Practice Address - Fax:803-296-7061
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC4894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant