Provider Demographics
NPI:1144299462
Name:MOORE, KATHY MILDREW (R D)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:MILDREW
Last Name:MOORE
Suffix:
Gender:F
Credentials:R D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EMANCIPATION DR
Mailing Address - Street 2:NUTRITION AND FOOD SERVICE
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23667-0001
Mailing Address - Country:US
Mailing Address - Phone:757-722-9961
Mailing Address - Fax:757-728-3468
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:NUTRITION AND FOOD SERVICE
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:757-728-3468
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA402442133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered