Healthcare Provider Details

I. General information

NPI: 1043173875
Provider Name (Legal Business Name): KELSEY EILEEN MOE PCP-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

IV. Provider business mailing address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number202530200
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: