Provider Demographics
NPI:1144986274
Name:MOSS, KATELYN R (LDH)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:R
Last Name:MOSS
Suffix:
Gender:F
Credentials:LDH
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:R
Other - Last Name:MCCRACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDH
Mailing Address - Street 1:1712 S ARMSTRONG ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-2034
Mailing Address - Country:US
Mailing Address - Phone:765-667-1139
Mailing Address - Fax:
Practice Address - Street 1:3118 S LAFOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3710
Practice Address - Country:US
Practice Address - Phone:765-864-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13007458A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist