Provider Demographics
NPI:1740712710
Name:MOORE, KATHRYN MARIE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MARIE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3890 G P EASTERLY RD
Mailing Address - Street 2:
Mailing Address - City:WEST FARMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44491-8733
Mailing Address - Country:US
Mailing Address - Phone:330-506-4762
Mailing Address - Fax:
Practice Address - Street 1:141 N FORGE ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1407
Practice Address - Country:US
Practice Address - Phone:330-375-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.014318207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program