Healthcare Provider Details

I. General information

NPI: 1477738458
Provider Name (Legal Business Name): JEAN ANN MOORMAN RN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax: 316-634-3014
Mailing address:
  • Phone: 316-685-2221
  • Fax: 316-634-3014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number13-30884-021
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberCDE 0892-7327
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: