Healthcare Provider Details

I. General information

NPI: 1063734762
Provider Name (Legal Business Name): BRITTANY LEANNE MOORE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BOURNE AVE
SOMERSET KY
42501-1916
US

IV. Provider business mailing address

500 BOURNE AVE
SOMERSET KY
42501-1916
US

V. Phone/Fax

Practice location:
  • Phone: 606-678-4761
  • Fax: 606-676-9671
Mailing address:
  • Phone: 606-678-4761
  • Fax: 606-676-9671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2260
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberKY-2176
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: