Provider Demographics
NPI:1346595154
Name:MOORE, ROBERT KEITH (RN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:KEITH
Last Name:MOORE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 POST RD
Mailing Address - Street 2:709
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-9601
Mailing Address - Country:US
Mailing Address - Phone:601-513-1108
Mailing Address - Fax:
Practice Address - Street 1:1465 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4719
Practice Address - Country:US
Practice Address - Phone:769-777-1058
Practice Address - Fax:769-230-2864
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882271163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse