Healthcare Provider Details

I. General information

NPI: 1871297119
Provider Name (Legal Business Name): KELLEY COURTNEY CUFFY-MOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 08/20/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SOUTHAMPTON AVE
NORFOLK VA
23510-1001
US

IV. Provider business mailing address

830 SOUTHAMPTON AVE
NORFOLK VA
23510-1001
US

V. Phone/Fax

Practice location:
  • Phone: 757-683-2718
  • Fax:
Mailing address:
  • Phone: 757-683-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001276761
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024186854
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: