Provider Demographics
NPI:1770357535
Name:MOORE, KIMMESHA
Entity type:Individual
Prefix:
First Name:KIMMESHA
Middle Name:
Last Name:MOORE
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 1:28 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08542-6901
Mailing Address - Country:US
Mailing Address - Phone:478-588-7339
Mailing Address - Fax:
Practice Address - Street 1:28 SPRING ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08542-6901
Practice Address - Country:US
Practice Address - Phone:478-588-7339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
28RW03886100183700000X
171W00000X
X9H6F9H4246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No183700000XPharmacy Service ProvidersPharmacy Technician
No171W00000XOther Service ProvidersContractor