Healthcare Provider Details

I. General information

NPI: 1164592457
Provider Name (Legal Business Name): KIMBERLY LEIGH MOORE RN CPNP-AC CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 MOTOR ST
DALLAS TX
75235-7701
US

IV. Provider business mailing address

3717 COLE AVE APARTMENT 274
DALLAS TX
75204-4502
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-2033
  • Fax:
Mailing address:
  • Phone: 919-225-4953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP114683
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number728846
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: