Provider Demographics
NPI:1194107631
Name:MOORE, AUDRA ELIZABETH (CRNP)
Entity type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:ELIZABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:ELIZABETH
Other - Last Name:ERNEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:1956 NORTHSIDE DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-2631
Mailing Address - Country:US
Mailing Address - Phone:256-777-0000
Mailing Address - Fax:
Practice Address - Street 1:6131 S NORCROSS TUCKER RD STE 6
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-5536
Practice Address - Country:US
Practice Address - Phone:678-205-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN266940363LF0000X
AL1-122815363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily