Provider Demographics
NPI:1063500486
Name:MOORE, KATHLEEN ANNE (RNC NNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RNC NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26452 CHAPEL HILL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-1808
Mailing Address - Country:US
Mailing Address - Phone:440-716-9752
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-5006
Practice Address - Country:US
Practice Address - Phone:216-844-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN218648363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner