Provider Demographics
NPI:1053604181
Name:MOORE, AUDREY KIM (NP)
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:KIM
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:KIM
Other - Last Name:LANGHORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:725 WELCH RD.
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304
Mailing Address - Country:US
Mailing Address - Phone:650-497-8800
Mailing Address - Fax:650-497-8034
Practice Address - Street 1:725 WELCH RD.
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304
Practice Address - Country:US
Practice Address - Phone:718-904-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF350322363LN0000X
CANP22335363LN0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal