Provider Demographics
NPI:1942556691
Name:MOULTRY, KORI KERON (RN)
Entity type:Individual
Prefix:MR
First Name:KORI
Middle Name:KERON
Last Name:MOULTRY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9111 CREEKS GATE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-5066
Mailing Address - Country:US
Mailing Address - Phone:832-654-5038
Mailing Address - Fax:
Practice Address - Street 1:9111 CREEKS GATE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-5066
Practice Address - Country:US
Practice Address - Phone:832-654-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX702831163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse