Healthcare Provider Details

I. General information

NPI: 1689009110
Provider Name (Legal Business Name): KELLY MICHELLE MOQUIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 E BALL RD STE 200
ANAHEIM CA
92806-5157
US

IV. Provider business mailing address

4860 Y ST
SACRAMENTO CA
95817-2309
US

V. Phone/Fax

Practice location:
  • Phone: 714-517-6300
  • Fax: 714-517-6306
Mailing address:
  • Phone: 916-734-3630
  • Fax: 916-734-0849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA164784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: