Provider Demographics
NPI:1558692897
Name:MOORE, KATHLEEN L (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:FREEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13068-9780
Mailing Address - Country:US
Mailing Address - Phone:607-347-6504
Mailing Address - Fax:
Practice Address - Street 1:99 WOOD RD
Practice Address - Street 2:
Practice Address - City:FREEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13068-9780
Practice Address - Country:US
Practice Address - Phone:607-347-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092130-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse