Provider Demographics
NPI:1972105054
Name:MOSS, KATY ANN
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:ANN
Last Name:MOSS
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 1:500 E COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-8048
Mailing Address - Country:US
Mailing Address - Phone:870-584-1053
Mailing Address - Fax:870-584-2087
Practice Address - Street 1:500 E COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-8048
Practice Address - Country:US
Practice Address - Phone:870-584-1053
Practice Address - Fax:870-584-2087
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR122438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily