Provider Demographics
NPI:1609293711
Name:MOATS, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MOATS
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 1:5055 E BROADWAY BLVD
Mailing Address - Street 2:A-100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3640
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:520-795-0225
Practice Address - Street 1:3043 W INA RD
Practice Address - Street 2:#115
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2107
Practice Address - Country:US
Practice Address - Phone:520-797-7070
Practice Address - Fax:520-797-7077
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily