Provider Demographics
NPI:1851048383
Name:MOORE, KELLY (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 PROVIDENCE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-5234
Mailing Address - Country:US
Mailing Address - Phone:610-213-5094
Mailing Address - Fax:
Practice Address - Street 1:7101 JAHNKE RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-4017
Practice Address - Country:US
Practice Address - Phone:804-483-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001251579163W00000X
VA0024186301367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse