Provider Demographics
NPI:1780128942
Name:MOORE, KELLY RENEE (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 MARGARET MICHELLE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4812
Mailing Address - Country:US
Mailing Address - Phone:314-520-1227
Mailing Address - Fax:
Practice Address - Street 1:130 ANDOR LN
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-4606
Practice Address - Country:US
Practice Address - Phone:314-520-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015105363LA2200X, 363LG0600X
MO2016029955363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1780128942OtherLICENSE