Provider Demographics
NPI:1972875995
Name:MOFFETT, KATELYN REBECCA (FNP-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:REBECCA
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4001
Mailing Address - Country:US
Mailing Address - Phone:601-703-5600
Mailing Address - Fax:601-703-5691
Practice Address - Street 1:1102 CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4001
Practice Address - Country:US
Practice Address - Phone:601-683-3117
Practice Address - Fax:601-683-2505
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04584751Medicaid