Provider Demographics
NPI:1467205302
Name:MOORE, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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 1:3001 LAKE TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:OH
Mailing Address - Zip Code:45106-8373
Mailing Address - Country:US
Mailing Address - Phone:513-884-3791
Mailing Address - Fax:
Practice Address - Street 1:3001 LAKE TRAIL LN
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:OH
Practice Address - Zip Code:45106-8373
Practice Address - Country:US
Practice Address - Phone:513-884-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant