Provider Demographics
NPI:1134635410
Name:MOORE, KEYOSHA
Entity Type:Individual
Prefix:
First Name:KEYOSHA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-3414
Mailing Address - Country:US
Mailing Address - Phone:262-880-6019
Mailing Address - Fax:262-880-6019
Practice Address - Street 1:6927 SKYLINE PARK DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-4353
Practice Address - Country:US
Practice Address - Phone:262-880-6019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31-197182163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0016649OtherSTATE OF WISCONSIN LISENCE