Provider Demographics
NPI:1992457147
Name:MOORE, NICOLE E
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:DE
Mailing Address - Zip Code:19968-1628
Mailing Address - Country:US
Mailing Address - Phone:302-684-0561
Mailing Address - Fax:
Practice Address - Street 1:424 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:DE
Practice Address - Zip Code:19968-1628
Practice Address - Country:US
Practice Address - Phone:302-684-0561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0048126163W00000X
DELG-0011888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse