Provider Demographics
NPI:1437843257
Name:MOORE, KEONDRA K
Entity type:Individual
Prefix:
First Name:KEONDRA
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4739 E PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-1656
Mailing Address - Country:US
Mailing Address - Phone:559-475-4876
Mailing Address - Fax:
Practice Address - Street 1:4739 E PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1656
Practice Address - Country:US
Practice Address - Phone:559-475-4876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula