Healthcare Provider Details

I. General information

NPI: 1285429340
Provider Name (Legal Business Name): KELLY MOSHOLDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 BLACKJACK RD
MOUNT VERNON OH
43050-9193
US

IV. Provider business mailing address

8402 BLACKJACK RD
MOUNT VERNON OH
43050-9193
US

V. Phone/Fax

Practice location:
  • Phone: 740-397-0442
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.377847
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: