Provider Demographics
NPI:1336389980
Name:MOORE, KATHRYN MARIE (RN, APRN-BC)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN, APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 CRESTCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4206
Mailing Address - Country:US
Mailing Address - Phone:404-558-1129
Mailing Address - Fax:
Practice Address - Street 1:2349 CRESTCLIFF DR
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4206
Practice Address - Country:US
Practice Address - Phone:404-558-1129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN171792363LC0200X
KY3005806363LA2100X, 363LA2200X, 363LG0600X
KY5806P363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology