Provider Demographics
NPI:1154844017
Name:MOORE, KELSEY (OD)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10600 OLD COUNTY ROAD 15
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6200
Mailing Address - Country:US
Mailing Address - Phone:763-545-8850
Mailing Address - Fax:763-544-1257
Practice Address - Street 1:10600 OLD COUNTY ROAD 15
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6200
Practice Address - Country:US
Practice Address - Phone:763-545-8850
Practice Address - Fax:763-544-1257
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3563152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy