Provider Demographics
NPI:1134628894
Name:MOORE, KIM LANERE (PCA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:LANERE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 JACK RABBIT WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-2633
Mailing Address - Country:US
Mailing Address - Phone:562-446-3076
Mailing Address - Fax:
Practice Address - Street 1:1832 JACK RABBIT WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-2633
Practice Address - Country:US
Practice Address - Phone:562-446-3076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant