Provider Demographics
NPI:1699243204
Name:MOORE, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MOORE
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 1:9103 COUNTRY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6650
Mailing Address - Country:US
Mailing Address - Phone:502-649-2954
Mailing Address - Fax:
Practice Address - Street 1:32270 TELEGRAPH RD STE 110
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-2456
Practice Address - Country:US
Practice Address - Phone:248-792-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601009656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program