Provider Demographics
NPI:1790483667
Name:MOORE, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
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 1:1711 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-2425
Mailing Address - Country:US
Mailing Address - Phone:251-246-5761
Mailing Address - Fax:251-246-5665
Practice Address - Street 1:1109 BOLL WEEVIL CIR STE 2
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-1454
Practice Address - Country:US
Practice Address - Phone:334-828-7591
Practice Address - Fax:334-828-7298
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH11229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist