Provider Demographics
NPI:1861155178
Name:MOORE, ANGELA VICTORIA (MSN, FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:VICTORIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSN, FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 RYAN AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-1281
Mailing Address - Country:US
Mailing Address - Phone:586-202-3763
Mailing Address - Fax:
Practice Address - Street 1:850 W BARAGA AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4550
Practice Address - Country:US
Practice Address - Phone:906-449-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704290287363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily