Provider Demographics
NPI:1538120746
Name:MOORE, KELLYANNA J (MD)
Entity Type:Individual
Prefix:
First Name:KELLYANNA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-5503
Mailing Address - Country:US
Mailing Address - Phone:507-451-1120
Mailing Address - Fax:507-444-6287
Practice Address - Street 1:2200 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-5503
Practice Address - Country:US
Practice Address - Phone:507-451-1120
Practice Address - Fax:507-444-6287
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN854628200Medicaid
080014757Medicare ID - Type Unspecified
MN854628200Medicaid