Provider Demographics
NPI:1336820588
Name:MOORHEAD, KAILEY BREAUN
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:BREAUN
Last Name:MOORHEAD
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 1:3245 GLENN MCCONNELL PKWY UNIT 413
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-8157
Mailing Address - Country:US
Mailing Address - Phone:806-241-5911
Mailing Address - Fax:
Practice Address - Street 1:3245 GLENN MCCONNELL PKWY UNIT 413
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-8157
Practice Address - Country:US
Practice Address - Phone:806-241-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX915420163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse