Provider Demographics
NPI:1396168118
Name:MOORE, MANDY LYNN (ARNP)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:LYNN
Other - Last Name:WOODRUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LANE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:1920 DON WICKHAM DRIVE
Practice Address - Street 2:SUIT 330
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-241-4298
Practice Address - Fax:352-241-7620
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9207746363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012103300Medicaid
FLHR857YMedicare PIN