MEDICARE: MR. KENNETH LEVI MOORE III CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	273520	OH

General Provider Information

NPI Number	:	1013995323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH LEVI MOORE III CNP

Provider Business Mailing Address
First Line	:	415 BYERS RD STE 300
Second Line	:
City	:	MIAMISBURG
State	:	OH
Zip	:	45342-3684
Country	:	US
Telephone Number	:	937-866-2494
Fax Number	:	937-866-8494

Provider Business Practice Location Address
First Line	:	101 E ALEX BELL RD STE 190
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-2752
Country	:	US
Telephone Number	:	937-425-4030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	10/02/2025

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