Provider Demographics
NPI:1134534589
Name:MOSHER, JOAN M (ARNP)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
Last Name:MOSHER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 KEPNER DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5144
Mailing Address - Country:US
Mailing Address - Phone:850-428-1623
Mailing Address - Fax:
Practice Address - Street 1:7456 NAVARRE PKWY
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-8192
Practice Address - Country:US
Practice Address - Phone:850-626-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9311885363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012383100Medicaid
FL012383100Medicaid