Basic Information
Provider Information
NPI: 1366172843
EntityType: 2
ReplacementNPI:  
OrganizationName: MOOREHALTH
LastName:  
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Credential:  
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Mailing Information
Address1: PO BOX 188
Address2:  
City: COOKSTOWN
State: NJ
PostalCode: 085110188
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 532 MARLTON PIKE W
Address2: #407
City: MARLTON
State: NJ
PostalCode: 080532075
CountryCode: US
TelephoneNumber: 3479127566
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/16/2022
LastUpdateDate: 06/16/2022
NPIDeactivationReasonCode:  
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NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MOORE
AuthorizedOfficialFirstName: OLIVER
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PMHNP-BC
AuthorizedOfficialTelephone: 2678041575
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential: DNP
NPICertificationDate: 06/06/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LP0808X  Y193400000X SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health

No ID Information.


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