Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | OT2017-008 | AR |
NPI | 1003343781 |
---|---|
Provider Name | Kristian Nicole Moore |
First Address | Forrest City, AR 72335-7435 |
Second Address | Forrest City, AR 72335-7435 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2017 |
Last Update Date | 12/05/2017 |