Healthcare Provider Details

I. General information

NPI: 1629531223
Provider Name (Legal Business Name): COURTNEY L MOELLER PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

IV. Provider business mailing address

3317 AUGUSTA AVE
CINCINNATI OH
45211-3501
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2663
  • Fax:
Mailing address:
  • Phone: 419-509-5802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005336
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: