Basic Information
| Provider Information | |||||||||
| NPI: | 1457633034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KENYATTA | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 NEWITT VICK DR | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391838782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015291445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 106 CLINTON PKWY | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390564730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019249005 | ||||||||
| FaxNumber: | 6019731622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2011 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R871546 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.