1013554054 NPI number — MRS. KRISSA L MOORE MS

Table of content: MRS. KRISSA L MOORE MS (NPI 1013554054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013554054 NPI number — MRS. KRISSA L MOORE MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
KRISSA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOK
Provider Other First Name:
KRISSA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013554054
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 173
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAR
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19701-0173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-397-4628
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 DEASY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19702-2750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-397-4628
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  37PC00702400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: PC-0011189 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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