Provider Demographics
NPI:1982489332
Name:MOSS, KENYA D (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KENYA
Middle Name:D
Last Name:MOSS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16700 LUELLA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2619
Mailing Address - Country:US
Mailing Address - Phone:708-715-7320
Mailing Address - Fax:
Practice Address - Street 1:4321 FIR ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3049
Practice Address - Country:US
Practice Address - Phone:219-392-7446
Practice Address - Fax:219-392-7470
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28201922A363LP0808X
IN71014366A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health