Provider Demographics
NPI:1063734762
Name:MOORE, BRITTANY LEANNE (RD)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:LEANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1916
Mailing Address - Country:US
Mailing Address - Phone:606-678-4761
Mailing Address - Fax:606-676-9671
Practice Address - Street 1:500 BOURNE AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-1916
Practice Address - Country:US
Practice Address - Phone:606-678-4761
Practice Address - Fax:606-676-9671
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2260133V00000X
KYKY-2176133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20001012Medicaid
KY20074019Medicaid
KY20100012Medicaid
KY20044012Medicaid
KY20101014Medicaid
KY20023016Medicaid
KY20029013Medicaid
KY20116018Medicaid
KY20901211Medicaid
KY20027017Medicaid
KY20109013Medicaid
KY20027017Medicaid
KY0300222Medicare PIN
KY20116018Medicaid
KY20100012Medicaid
KY0300719Medicare PIN
KY20901211Medicaid
KY20109013Medicaid
KY0300618Medicare PIN