Provider Demographics
NPI:1639390768
Name:MOORE, KAMI OPAL (CNS)
Entity Type:Individual
Prefix:
First Name:KAMI
Middle Name:OPAL
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 S UTICA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4243
Mailing Address - Country:US
Mailing Address - Phone:918-592-0999
Mailing Address - Fax:918-392-0341
Practice Address - Street 1:1265 S UTICA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4243
Practice Address - Country:US
Practice Address - Phone:918-592-0999
Practice Address - Fax:918-392-0341
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0075063364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK700116OtherMEDICARE PTAN
OKP00637856OtherMEDICARE RAILROAD
OK200112940AMedicaid