Healthcare Provider Details

I. General information

NPI: 1992212302
Provider Name (Legal Business Name): KAITLYN VIRGINIA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BOWMAN RD
SPRINGFIELD OH
45505-1814
US

IV. Provider business mailing address

600 BOWMAN RD
SPRINGFIELD OH
45505-1814
US

V. Phone/Fax

Practice location:
  • Phone: 937-360-5711
  • Fax:
Mailing address:
  • Phone: 937-360-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberUD491708
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberUD491708
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: