Provider Demographics
NPI:1013518661
Name:MOORE, KIMBERLY SUE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
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 341
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVET
Mailing Address - State:KY
Mailing Address - Zip Code:41064-0341
Mailing Address - Country:US
Mailing Address - Phone:606-842-0258
Mailing Address - Fax:
Practice Address - Street 1:150 CLOVE RD STE 2
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07424-2139
Practice Address - Country:US
Practice Address - Phone:973-826-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1099445363LF0000X
KY3014345363LF0000X
NJ26NJ01212500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily