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General NPI Number Information
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NPI Number | 1427254614
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Entity Type | Individual
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Provider Name | MRS. KELLEY ANN MOORE-SOUTH
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Gender | Female
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Dates
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Enumeration Date | 06/25/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1645 MAPLEWOOD DR
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City | STREETSBORO
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State | OH
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Zip | 44241-5662
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Country | US
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Telephone | 330-626-3031
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Fax |
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Provider Business Mailing Address
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Address Line | 1579 RUSSELL DR
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City | STREETSBORO
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State | OH
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Zip | 44241-8349
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Country | US
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Telephone | 330-422-1304
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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