Healthcare Provider Details

I. General information

NPI: 1649049305
Provider Name (Legal Business Name): KELLY MARIE MOORE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARIE SMITH

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 WOODLEY AVE
ENCINO CA
91436-1443
US

IV. Provider business mailing address

6109 ENFIELD PL
RIVERSIDE CA
92506-4712
US

V. Phone/Fax

Practice location:
  • Phone: 628-432-7476
  • Fax: 888-385-7037
Mailing address:
  • Phone: 951-990-2381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028281
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025085121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: