Provider Demographics
NPI:1134507155
Name:MOORES, KELLY DAWN (MS)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DAWN
Last Name:MOORES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 SACARAP RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:ME
Mailing Address - Zip Code:04623-3310
Mailing Address - Country:US
Mailing Address - Phone:207-483-4638
Mailing Address - Fax:207-483-4638
Practice Address - Street 1:283 SACARAP RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:ME
Practice Address - Zip Code:04623-3310
Practice Address - Country:US
Practice Address - Phone:207-483-4638
Practice Address - Fax:207-483-4638
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner