Healthcare Provider Details

I. General information

NPI: 1477301604
Provider Name (Legal Business Name): KIMBERLY MOORE LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 S RIDGE RD
GREEN BAY WI
54304-4125
US

IV. Provider business mailing address

310 MADISON WAY APT 5
SHAWANO WI
54166-3872
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4888
  • Fax:
Mailing address:
  • Phone: 210-379-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3155-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: