Provider Demographics
NPI:1609652023
Name:MOORE, KIMBERLY (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 VAN PL
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-3168
Mailing Address - Country:US
Mailing Address - Phone:307-254-3249
Mailing Address - Fax:
Practice Address - Street 1:1420 STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-4322
Practice Address - Country:US
Practice Address - Phone:360-854-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61281873163WM0705X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical