Basic Information
| Provider Information | |||||||||
| NPI: | 1083075758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | MOIRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HECKER | ||||||||
| OtherFirstName: | MOIRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE. | ||||||||
| Address2: | MLC 2023 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364371 | ||||||||
| FaxNumber: | 5136367657 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | MLC 2023 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364371 | ||||||||
| FaxNumber: | 5136367657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2016 | ||||||||
| LastUpdateDate: | 04/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.18621 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0161909 | 05 | OH | MEDICAID |