Basic Information
| Provider Information | |||||||||
| NPI: | 1114516812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | THERESE | ||||||||
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| Credential: | RN, DNP STUDENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3240 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606512405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124137425 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3240 W DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606512405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124137425 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2021 | ||||||||
| LastUpdateDate: | 01/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP2201X | 041487884 | IL | Y | Nursing Service Providers | Registered Nurse | Ambulatory Care |
No ID Information.