Healthcare Provider Details

I. General information

NPI: 1720287360
Provider Name (Legal Business Name): KELLY CORINNE MOYNAHAN MA, CAS, LPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E ARLINGTON BLVD PARLIAMENT PLACE, SUITE 7
GREENVILLE NC
27858-5037
US

IV. Provider business mailing address

300 E ARLINGTON BLVD PARLIAMENT PLACE, SUITE 7
GREENVILLE NC
27858-5037
US

V. Phone/Fax

Practice location:
  • Phone: 252-227-3247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3377
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: