Provider Demographics
NPI:1538983598
Name:MOORE, KEYONNA CHAVONTREL
Entity type:Individual
Prefix:
First Name:KEYONNA
Middle Name:CHAVONTREL
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W PINHOOK RD STE 211
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2499
Mailing Address - Country:US
Mailing Address - Phone:337-345-8576
Mailing Address - Fax:
Practice Address - Street 1:1001 W PINHOOK RD STE 211
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2499
Practice Address - Country:US
Practice Address - Phone:337-345-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA9417225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist