Provider Demographics
NPI:1639669336
Name:MOORE, KYLIE
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
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 1:1474 BMADZEWEN WAY
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MI
Mailing Address - Zip Code:49052-9623
Mailing Address - Country:US
Mailing Address - Phone:269-729-4422
Mailing Address - Fax:
Practice Address - Street 1:1474 BMADZEWEN WAY
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MI
Practice Address - Zip Code:49052-9623
Practice Address - Country:US
Practice Address - Phone:269-729-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker