Provider Demographics
NPI:1043742414
Name:MOELLER, KELSIE LYNN
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:LYNN
Last Name:MOELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 E TURKEYFOOT LAKE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-5277
Mailing Address - Country:US
Mailing Address - Phone:330-899-5437
Mailing Address - Fax:330-899-5447
Practice Address - Street 1:1622 E TURKEYFOOT LAKE RD STE 100
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-5277
Practice Address - Country:US
Practice Address - Phone:330-899-5437
Practice Address - Fax:330-899-5447
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139222208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program