Healthcare Provider Details

I. General information

NPI: 1235875196
Provider Name (Legal Business Name): KATHERINE AINSLEY MOORE CNC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4564 S HARVARD AVE STE B
TULSA OK
74135-2918
US

IV. Provider business mailing address

4564 S HARVARD AVE STE B
TULSA OK
74135-2918
US

V. Phone/Fax

Practice location:
  • Phone: 918-508-2220
  • Fax:
Mailing address:
  • Phone: 918-508-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1220801859
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: