Healthcare Provider Details

I. General information

NPI: 1952118937
Provider Name (Legal Business Name): KELLEY MOQUIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N GROVE ST
MIDDLEBORO MA
02346-1407
US

IV. Provider business mailing address

65 N GROVE ST
MIDDLEBORO MA
02346-1407
US

V. Phone/Fax

Practice location:
  • Phone: 508-406-8331
  • Fax:
Mailing address:
  • Phone: 508-406-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2288418
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: