Healthcare Provider Details

I. General information

NPI: 1780594051
Provider Name (Legal Business Name): KRISTON LEEANN BALFOUR MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 HONOR HEIGHTS DR
MUSKOGEE OK
74401-1318
US

IV. Provider business mailing address

421034 E 1010 RD
OKTAHA OK
74450-2801
US

V. Phone/Fax

Practice location:
  • Phone: 918-577-3000
  • Fax:
Mailing address:
  • Phone: 918-639-2269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR008006
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: