Healthcare Provider Details

I. General information

NPI: 1649193582
Provider Name (Legal Business Name): MAKENNA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 27TH ST
DES MOINES IA
50310-5400
US

IV. Provider business mailing address

6201 EP TRUE PKWY APT 8111
WEST DES MOINES IA
50266-5225
US

V. Phone/Fax

Practice location:
  • Phone: 515-612-7747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number137115
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: