Provider Demographics
NPI:1548745037
Name:MORENO, KRISTIN M (PA-C, MPH)
Entity Type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:M
Last Name:MORENO
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:M
Other - Last Name:KAMPENGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-3420
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1251 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3221
Practice Address - Country:US
Practice Address - Phone:321-434-3420
Practice Address - Fax:321-434-3423
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111626363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLKN334OtherMEDICARE HFPSI
FL101537200Medicaid
FLKM444OtherMEDICARE HFMG