Provider Demographics
NPI:1255741294
Name:MOORE, NICOLE (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 EXPLORER DR APT 207
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-9191
Mailing Address - Country:US
Mailing Address - Phone:607-267-2706
Mailing Address - Fax:
Practice Address - Street 1:409 E OAKLAND AVE UNIT B
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:FL
Practice Address - Zip Code:34787-3070
Practice Address - Country:US
Practice Address - Phone:407-654-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 15543225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics