MEDICARE: KAILO'S MENTAL RETREAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1427945518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAILO'S MENTAL RETREAT

Provider Business Mailing Address
First Line	:	748 ADDINGTON DR
Second Line	:
City	:	WINTERVILLE
State	:	NC
Zip	:	28590-7102
Country	:	US
Telephone Number	:	252-414-3318
Fax Number	:	252-677-6551

Provider Business Practice Location Address
First Line	:	748 ADDINGTON DR
Second Line	:
City	:	WINTERVILLE
State	:	NC
Zip	:	28590-7102
Country	:	US
Telephone Number	:	252-414-3318
Fax Number	:	252-677-6551

Authorized Official
Title or Position	:	MSN, PMHNP-C
Name	:	LISA MICHELLE MOORE
Credential	:	PMHNP-C
Telephone Number	:	252-414-3318

Provider Enumeration Date	:	06/20/2025
Last Update Date	:	02/20/2026

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