1629670203 NPI number — SENAN ISABELLE KAKPO-MOORE PA-C

Table of content: SENAN ISABELLE KAKPO-MOORE PA-C (NPI 1629670203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629670203 NPI number — SENAN ISABELLE KAKPO-MOORE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAKPO-MOORE
Provider First Name:
SENAN
Provider Middle Name:
ISABELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KAKPO-MOORE
Provider Other First Name:
SENAN
Provider Other Middle Name:
ISABELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629670203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 WOODMONT BLVD STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205-2245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12998 HESPERIA RD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-8317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-780-4960
Provider Business Practice Location Address Fax Number:
760-780-4964
Provider Enumeration Date:
11/10/2020

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA60419 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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