Healthcare Provider Details

I. General information

NPI: 1609852722
Provider Name (Legal Business Name): KELLY J MOYER M.S., C.G.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KELLY J CONNERTON-MOYER M.S., C.G.C.

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 SOUTH FIRST AVE RM.1024/BUILD 103 - OB/GYN, LUMC
MAYWOOD IL
60153
US

IV. Provider business mailing address

1152 S GROVE AVE
OAK PARK IL
60304-1941
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-8167
  • Fax:
Mailing address:
  • Phone: 708-445-9917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: