Healthcare Provider Details

I. General information

NPI: 1013227206
Provider Name (Legal Business Name): KANIKA SHUKURA MOXLEY RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 NORTON ST
ROCHESTER NY
14621-3732
US

IV. Provider business mailing address

579 KATHRINE STREET
ORLANDO FL
32810
US

V. Phone/Fax

Practice location:
  • Phone: 585-719-9799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22 522778
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: