Provider Demographics
NPI:1235948456
Name:MOORE, JOHNNY CLIFTON
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:CLIFTON
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 CLEVES AVE
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-1881
Mailing Address - Country:US
Mailing Address - Phone:693-200-0007
Mailing Address - Fax:
Practice Address - Street 1:860 HEBRON PKWY STE 1101
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5147
Practice Address - Country:US
Practice Address - Phone:469-444-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1184125363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health