Provider Demographics
NPI:1801290242
Name:MOORE, KRISTIE
Entity type:Individual
Prefix:
First Name:KRISTIE
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:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-0818
Mailing Address - Country:US
Mailing Address - Phone:912-754-0380
Mailing Address - Fax:912-754-1037
Practice Address - Street 1:3 HIDDEN CREEK DR
Practice Address - Street 2:
Practice Address - City:GUYTON
Practice Address - State:GA
Practice Address - Zip Code:31312-4590
Practice Address - Country:US
Practice Address - Phone:912-772-8670
Practice Address - Fax:912-754-1037
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily