Provider Demographics
NPI:1821532391
Name:MOORE, KELSEY LYNN (NP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:LYNN
Other - Last Name:VANNOSTRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8 CAVOUR CIR
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-1906
Mailing Address - Country:US
Mailing Address - Phone:508-439-0227
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-439-0227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-18
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2295244363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics