Provider Demographics
NPI:1992212211
Name:MOORE, KIMBRA LEE
Entity Type:Individual
Prefix:
First Name:KIMBRA
Middle Name:LEE
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 1:128 S WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2634
Mailing Address - Country:US
Mailing Address - Phone:419-231-5351
Mailing Address - Fax:
Practice Address - Street 1:128 S WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2634
Practice Address - Country:US
Practice Address - Phone:419-231-5351
Practice Address - Fax:419-302-1481
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.020726363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology