MEDICARE: KAITLYN RAE MOELLER

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1881440980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN RAE MOELLER

Provider Business Mailing Address
First Line	:	1967 PINELAWN DR
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43614-3534
Country	:	US
Telephone Number	:	419-280-1692
Fax Number	:

Provider Business Practice Location Address
First Line	:	1632 E PERRY ST
Second Line	:
City	:	PORT CLINTON
State	:	OH
Zip	:	43452-1332
Country	:	US
Telephone Number	:	419-960-5559
Fax Number	:

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

Provider Enumeration Date	:	04/29/2024
Last Update Date	:	04/29/2024

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