Provider Demographics
NPI:1649727850
Name:MOULTRY, KAMESHA DEES (CRNP)
Entity type:Individual
Prefix:MRS
First Name:KAMESHA
Middle Name:DEES
Last Name:MOULTRY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 HARTFORD HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4927
Mailing Address - Country:US
Mailing Address - Phone:334-712-1170
Mailing Address - Fax:
Practice Address - Street 1:1970 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3726
Practice Address - Country:US
Practice Address - Phone:334-774-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-101408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily