Provider Demographics
NPI:1487916250
Name:MOORE, KIM MARIE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:MOORE
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 1:1670 E 120TH ST
Mailing Address - Street 2:N S BLDG ROOM 2C06
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3026
Mailing Address - Country:US
Mailing Address - Phone:424-338-1501
Mailing Address - Fax:310-632-3748
Practice Address - Street 1:1670 E 120TH ST
Practice Address - Street 2:N S BLDG ROOM 2C06
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3026
Practice Address - Country:US
Practice Address - Phone:424-338-1501
Practice Address - Fax:310-632-3748
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily