Provider Demographics
NPI:1275819674
Name:MORELAND, KATHRYN CORINNE (NP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CORINNE
Last Name:MORELAND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4215
Mailing Address - Country:US
Mailing Address - Phone:817-335-5288
Mailing Address - Fax:817-394-6294
Practice Address - Street 1:1201 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4215
Practice Address - Country:US
Practice Address - Phone:817-335-5288
Practice Address - Fax:817-338-0927
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP121079363L00000X
TX734380363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX734380OtherTEXAS RN LICENSE
TXAP121079OtherTEXAS NURSE PRACTITIONER LICENSE
TX294313601Medicaid