Provider Demographics
NPI:1316929839
Name:MOORE, VICKIE B (NP)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:B
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2728 OLD FOREST ROAD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2435
Mailing Address - Country:US
Mailing Address - Phone:434-385-7818
Mailing Address - Fax:434-385-7820
Practice Address - Street 1:2728 OLD FOREST ROAD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2435
Practice Address - Country:US
Practice Address - Phone:434-385-7818
Practice Address - Fax:434-385-7820
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024059060363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007780125Medicaid
VA500000734Medicare ID - Type Unspecified
VA007780125Medicaid