Basic Information
| Provider Information | |||||||||
| NPI: | 1487149324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KELITA | ||||||||
| MiddleName: | LESHEA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2912 STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486023743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895290027 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1320 N MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894019015 | ||||||||
| FaxNumber: | 9894019018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2018 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 4703096951 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.