Provider Demographics
NPI:1205230950
Name:MOOR, MCKENZIE LARAE (PMHNP)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LARAE
Last Name:MOOR
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 14TH ST W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4076
Mailing Address - Country:US
Mailing Address - Phone:701-572-3335
Mailing Address - Fax:701-572-3337
Practice Address - Street 1:1500 14TH ST W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4076
Practice Address - Country:US
Practice Address - Phone:701-572-3335
Practice Address - Fax:701-572-3337
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR40835163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse