MEDICARE: KELLY NICOLE MORALES MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	61216	SC
2	207Q00000X	Family Medicine Physician	7695	KS
3	207Q00000X	Family Medicine Physician	DR.0054489	CO

General Provider Information

NPI Number	:	1306132881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY NICOLE MORALES MD

Provider Business Mailing Address
First Line	:	4920 OHEAR AVE
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-5093
Country	:	US
Telephone Number	:	574-238-9266
Fax Number	:	843-856-3788

Provider Business Practice Location Address
First Line	:	4920 OHEAR AVE
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29405-5093
Country	:	US
Telephone Number	:	843-856-3784
Fax Number	:	843-856-3788

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	10/05/2023

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