Basic Information
| Provider Information | |||||||||
| NPI: | 1104160217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KAYELA | ||||||||
| MiddleName: | FAYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRAWIEC | ||||||||
| OtherFirstName: | KAYELA | ||||||||
| OtherMiddleName: | FAYE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13500 SUTTON PARK DRIVE SOUTH | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322245291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Practice Location | |||||||||
| Address1: | 13500 SUTTON PARK DRIVE SOUTH | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322245291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044933390 | ||||||||
| FaxNumber: | 9044933395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 09/11/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9233632 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | ARNP9233632 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 45681 | 01 | FL | MEDICARE - GROUP | OTHER | HL342Z | 01 | FL | MEDICARE - INDIVIDUAL | OTHER | 9233632 | 01 | FL | FL ARNP LICENSE | OTHER |