Provider Demographics
NPI:1114516812
Name:MOORE, KELLY THERESE (RN, DNP STUDENT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:THERESE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN, DNP STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-2405
Mailing Address - Country:US
Mailing Address - Phone:312-413-7425
Mailing Address - Fax:
Practice Address - Street 1:3240 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-2405
Practice Address - Country:US
Practice Address - Phone:312-413-7425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041487884163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care