Provider Demographics
NPI:1205331600
Name:SUTHERLAND, KELLY MOORE (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MOORE
Last Name:SUTHERLAND
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:
Practice Address - Street 1:3581 HARRODSBURG RD STE 350
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1140
Practice Address - Country:US
Practice Address - Phone:859-313-6333
Practice Address - Fax:859-313-3484
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR48112084P0800X
KY048492084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100616800Medicaid