Provider Demographics
NPI:1962520841
Name:MOYNAHAN, MARY THURSTON (FNP, BC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:THURSTON
Last Name:MOYNAHAN
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 HIGH DUNE LOOP
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3710
Mailing Address - Country:US
Mailing Address - Phone:252-261-1222
Mailing Address - Fax:
Practice Address - Street 1:109 EXETER STREET
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954-1000
Practice Address - Country:US
Practice Address - Phone:252-475-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
2804899Medicare ID - Type Unspecified
NCP55683Medicare UPIN