Provider Demographics
NPI:1932448206
Name:MOORE, KATHLEEN L (RD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:L
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, CDE
Mailing Address - Street 1:3267 MINERAL SPRINGS TRL
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9694
Mailing Address - Country:US
Mailing Address - Phone:989-954-5380
Mailing Address - Fax:
Practice Address - Street 1:3267 MINERAL SPRINGS TRL
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9694
Practice Address - Country:US
Practice Address - Phone:989-954-5380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-06
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1006X
OHLD.08856133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic