Provider Demographics
NPI:1730068578
Name:KELLY MORENO, JOHN BRYAN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRYAN
Last Name:KELLY MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MIRADERO GARDENS CALLE COQUI 719
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00682
Mailing Address - Country:US
Mailing Address - Phone:787-552-0318
Mailing Address - Fax:
Practice Address - Street 1:EDIFICIO A, 917 AV. TITO CASTRO PISO 4
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00732
Practice Address - Country:US
Practice Address - Phone:787-844-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program