Provider Demographics
NPI:1891814703
Name:MOORE, KRISTY D (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 HIGHWAY 1228
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-7532
Mailing Address - Country:US
Mailing Address - Phone:318-254-2557
Mailing Address - Fax:
Practice Address - Street 1:401 E VAUGHN AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5950
Practice Address - Country:US
Practice Address - Phone:318-254-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA074320367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA074320OtherCRNA CERTIFICATION NO.
LA1024252Medicaid
LAH6497OtherBLUE CROSS BLUE SHIELD
LA074320OtherCRNA CERTIFICATION NO.