Provider Demographics
NPI:1477670594
Name:MOORE, KELLY (PT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 672075
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-2075
Mailing Address - Country:US
Mailing Address - Phone:907-726-4663
Mailing Address - Fax:844-605-1820
Practice Address - Street 1:22502 SAMBAR LOOP
Practice Address - Street 2:
Practice Address - City:CHUGIAK
Practice Address - State:AK
Practice Address - Zip Code:99567-5377
Practice Address - Country:US
Practice Address - Phone:907-726-4663
Practice Address - Fax:844-605-1820
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011150225100000X
AK800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT4330Medicaid