Provider Demographics
NPI:1053573717
Name:MOORE, KATHLEEN MARIE (APRN-CNP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:MASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-366-3687
Mailing Address - Fax:614-293-9698
Practice Address - Street 1:915 OLENTANGY RIVER RD STE 4000
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3154
Practice Address - Country:US
Practice Address - Phone:614-366-3687
Practice Address - Fax:614-293-9698
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.13664363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0079512Medicaid
OHH185430Medicare PIN