Provider Demographics
NPI:1770977563
Name:MOORE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W 16TH ST # 1128
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4733
Mailing Address - Country:US
Mailing Address - Phone:907-931-8618
Mailing Address - Fax:
Practice Address - Street 1:101 W 16TH ST # 1128
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4733
Practice Address - Country:US
Practice Address - Phone:907-931-8618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK37437163W00000X
AK162387363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse