Healthcare Provider Details

I. General information

NPI: 1780128942
Provider Name (Legal Business Name): KELLY RENEE MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ANDOR LN
HILLSBORO MO
63050-4606
US

IV. Provider business mailing address

224 MARGARET MICHELLE CT
SAINT PETERS MO
63376-4812
US

V. Phone/Fax

Practice location:
  • Phone: 314-520-1227
  • Fax:
Mailing address:
  • Phone: 314-520-1227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.015105
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2016029955
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.015105
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016029955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: