Provider Demographics
NPI:1689009110
Name:MOQUIN, KELLY MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELLE
Last Name:MOQUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4860 Y ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2309
Mailing Address - Country:US
Mailing Address - Phone:916-734-3630
Mailing Address - Fax:916-734-0849
Practice Address - Street 1:2035 E BALL RD STE 200
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-5157
Practice Address - Country:US
Practice Address - Phone:714-517-6300
Practice Address - Fax:714-517-6306
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1647842084P0800X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine