Provider Demographics
NPI:1730817354
Name:MOORE, CHARLOTTE R (NP)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 ACCABONAC RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-1932
Mailing Address - Country:US
Mailing Address - Phone:631-324-3344
Mailing Address - Fax:
Practice Address - Street 1:316 ACCABONAC RD
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-1932
Practice Address - Country:US
Practice Address - Phone:631-324-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403286363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health