Provider Demographics
NPI:1942035662
Name:MOORE, KYNNEDY JANEECE
Entity type:Individual
Prefix:
First Name:KYNNEDY
Middle Name:JANEECE
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 1:2455 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-3996
Mailing Address - Country:US
Mailing Address - Phone:405-509-4851
Mailing Address - Fax:
Practice Address - Street 1:2455 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-3996
Practice Address - Country:US
Practice Address - Phone:405-509-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide