Provider Demographics
NPI:1427254614
Name:MOORE-SOUTH, KELLEY ANN
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ANN
Last Name:MOORE-SOUTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1579 RUSSELL DR
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-8349
Mailing Address - Country:US
Mailing Address - Phone:330-422-1304
Mailing Address - Fax:
Practice Address - Street 1:1645 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5662
Practice Address - Country:US
Practice Address - Phone:330-626-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2007563Medicaid
OH365718Medicare ID - Type Unspecified