Provider Demographics
NPI:1033455613
Name:MOORE, KATHY ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 THOMAS LANGSTON RD
Mailing Address - Street 2:UNIT 6
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8364
Mailing Address - Country:US
Mailing Address - Phone:252-544-1855
Mailing Address - Fax:
Practice Address - Street 1:1310 THOMAS LANGSTON RD
Practice Address - Street 2:UNIT 6
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8364
Practice Address - Country:US
Practice Address - Phone:252-544-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-30
Last Update Date:2012-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC70547164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse