Provider Demographics
NPI:1568822807
Name:MOYES, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1710
Mailing Address - Country:US
Mailing Address - Phone:973-895-3658
Mailing Address - Fax:
Practice Address - Street 1:35 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1710
Practice Address - Country:US
Practice Address - Phone:973-895-3658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00290900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant