Provider Demographics
NPI:1700552007
Name:MOORE, KELLY DIANE (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DIANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DIANE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:701 N CARMICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1160
Mailing Address - Country:US
Mailing Address - Phone:520-515-2950
Mailing Address - Fax:
Practice Address - Street 1:701 N CARMICHAEL AVE
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-1160
Practice Address - Country:US
Practice Address - Phone:520-515-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ224481163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool