Provider Demographics
NPI:1336862200
Name:MORACE, KATRINA LYNNE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LYNNE
Last Name:MORACE
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 1:124 STUART DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3706
Mailing Address - Country:US
Mailing Address - Phone:601-334-1192
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406
Practice Address - Country:US
Practice Address - Phone:601-334-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty