Provider Demographics
NPI:1992448054
Name:MOORE, KAYDEE M (RN)
Entity type:Individual
Prefix:
First Name:KAYDEE
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KAYDEE
Other - Middle Name:
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:545 AIRPORT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-7388
Mailing Address - Country:US
Mailing Address - Phone:304-325-0066
Mailing Address - Fax:
Practice Address - Street 1:545 AIRPORT RD STE 101
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-7388
Practice Address - Country:US
Practice Address - Phone:304-325-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-17
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36188164W00000X
WV114250163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse