Provider Demographics
NPI:1891184453
Name:MOORE, KAYDE
Entity Type:Individual
Prefix:
First Name:KAYDE
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:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:1111 GLYNCO PKWY STE 35
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7930
Practice Address - Country:US
Practice Address - Phone:912-304-7013
Practice Address - Fax:912-342-1025
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant