Provider Demographics
NPI:1902332166
Name:MOORE, KIANA
Entity Type:Individual
Prefix:
First Name:KIANA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIANA
Other - Middle Name:MICHELLE
Other - Last Name:PAULINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:319 MILLCREEK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-9001
Mailing Address - Country:US
Mailing Address - Phone:769-257-4843
Mailing Address - Fax:
Practice Address - Street 1:319 MILLCREEK DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-9001
Practice Address - Country:US
Practice Address - Phone:769-257-4843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker