Provider Demographics
NPI:1487149324
Name:MOORE, KELITA LESHEA (NURSE)
Entity type:Individual
Prefix:MS
First Name:KELITA
Middle Name:LESHEA
Last Name:MOORE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3743
Mailing Address - Country:US
Mailing Address - Phone:989-529-0027
Mailing Address - Fax:
Practice Address - Street 1:1320 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602
Practice Address - Country:US
Practice Address - Phone:989-401-9015
Practice Address - Fax:989-401-9018
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703096951164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty