Healthcare Provider Details

I. General information

NPI: 1922621770
Provider Name (Legal Business Name): KRYSTAL MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1396 E 93RD ST
CLEVELAND OH
44106-1006
US

IV. Provider business mailing address

1396 E 93RD ST
CLEVELAND OH
44106-1006
US

V. Phone/Fax

Practice location:
  • Phone: 216-800-1835
  • Fax:
Mailing address:
  • Phone: 216-800-1835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number541576
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: