Healthcare Provider Details

I. General information

NPI: 1790238160
Provider Name (Legal Business Name): KALI JO MOE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 E MAIN ST
CARBONDALE IL
62901-3148
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-2281
  • Fax: 618-351-5625
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021379
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340962
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: