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NPI Code Detail

MEDICARE: KELLY THERESE MOORE RN, DNP STUDENT

MEDICARE: KELLY THERESE MOORE RN, DNP STUDENT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WP2201XAmbulatory Care Registered Nurse041487884IL

General Provider Information

NPI Number : 1114516812
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY THERESE MOORE RN, DNP STUDENT
Provider Business Mailing Address
First Line : 3240 W DIVISION ST
Second Line :
City : CHICAGO
State : IL
Zip : 60651-2405
Country : US
Telephone Number : 312-413-7425
Fax Number :
Provider Business Practice Location Address
First Line : 3240 W DIVISION ST
Second Line :
City : CHICAGO
State : IL
Zip : 60651-2405
Country : US
Telephone Number : 312-413-7425
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/16/2021
Last Update Date : 01/16/2021

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