Provider Demographics
NPI:1417576695
Name:MOORE, KELLY (RN BSN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 PIERCE ST APT 201
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-4571
Mailing Address - Country:US
Mailing Address - Phone:314-780-5672
Mailing Address - Fax:
Practice Address - Street 1:1101 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6919
Practice Address - Country:US
Practice Address - Phone:314-600-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95030742163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine