Provider Demographics
NPI:1144778192
Name:MOYLAN, KELLI JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JEAN
Last Name:MOYLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:850-212-1040
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:457 RAILROAD ST STE 2
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1643
Practice Address - Country:US
Practice Address - Phone:802-633-6351
Practice Address - Fax:802-748-0977
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10094033-1206363AM0700X
VT055.0031485363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical