Provider Demographics
NPI: | 1710653407 |
---|---|
Name: | MOFFETT, RAECHELLE ANGELEE (CEO, LVN) |
Entity Type: | Individual |
Prefix: | |
First Name: | RAECHELLE |
Middle Name: | ANGELEE |
Last Name: | MOFFETT |
Suffix: | |
Gender: | F |
Credentials: | CEO, LVN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 5702 GREENGATE DR APT D |
Mailing Address - Street 2: | |
Mailing Address - City: | KILLEEN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76543-9006 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 254-681-7975 |
Mailing Address - Fax: | 254-699-4189 |
Practice Address - Street 1: | 5702 GREENGATE DR APT D |
Practice Address - Street 2: | |
Practice Address - City: | KILLEEN |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76543-9006 |
Practice Address - Country: | US |
Practice Address - Phone: | 254-245-8058 |
Practice Address - Fax: | 254-699-4189 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2021-08-21 |
Last Update Date: | 2023-06-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
253Z00000X, 310400000X, 320600000X, 251C00000X, 251J00000X, 332U00000X, 372500000X, 372600000X, 374U00000X, 261QA0600X, 320700000X, 320900000X | ||
TX | 327311 | 164X00000X, 164X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 164X00000X | Nursing Service Providers | Licensed Vocational Nurse | |
No | 253Z00000X | Agencies | In Home Supportive Care | |
No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | |
No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
No | 251J00000X | Agencies | Nursing Care | |
No | 332U00000X | Suppliers | Home Delivered Meals | |
No | 372500000X | Nursing Service Related Providers | Chore Provider | |
No | 372600000X | Nursing Service Related Providers | Adult Companion | |
No | 374U00000X | Nursing Service Related Providers | Home Health Aide | |
Yes | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
No | 320700000X | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities | |
No | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities |