Provider Demographics
NPI:1548527997
Name:MOSS, ENOS KENNETH JR (RN, MSN, ANP-BC)
Entity type:Individual
Prefix:MR
First Name:ENOS
Middle Name:KENNETH
Last Name:MOSS
Suffix:JR
Gender:M
Credentials:RN, MSN, ANP-BC
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12125 CONWAY ROAD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-251-2870
Mailing Address - Fax:
Practice Address - Street 1:14101 SULLYFIELD CIR STE 400A
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1781
Practice Address - Country:US
Practice Address - Phone:888-478-1882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012011952363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1548527997Medicaid