Provider Demographics
NPI:1710653407
Name:MOFFETT, RAECHELLE ANGELEE (CEO, LVN)
Entity type:Individual
Prefix:
First Name:RAECHELLE
Middle Name:ANGELEE
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:CEO, LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 GREENGATE DR APT D
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-9006
Mailing Address - Country:US
Mailing Address - Phone:254-681-7975
Mailing Address - Fax:254-699-4189
Practice Address - Street 1:5702 GREENGATE DR APT D
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-9006
Practice Address - Country:US
Practice Address - Phone:254-245-8058
Practice Address - Fax:254-699-4189
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 310400000X, 320600000X, 251C00000X, 251J00000X, 332U00000X, 372500000X, 372600000X, 374U00000X, 261QA0600X, 320700000X, 320900000X
TX327311164X00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251J00000XAgenciesNursing Care
No332U00000XSuppliersHome Delivered Meals
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities