Provider Demographics
NPI:1336110634
Name:MOORE, KELLY L (ARNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 4557
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4557
Mailing Address - Country:US
Mailing Address - Phone:866-290-4325
Mailing Address - Fax:515-280-9525
Practice Address - Street 1:2530 CHAMBERLAIN STREET
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014-7272
Practice Address - Country:US
Practice Address - Phone:866-290-4325
Practice Address - Fax:515-280-9525
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091298363LW0102X
IA091298NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P30891Medicare UPIN
I2029Medicare ID - Type Unspecified