Kelly Marie Moore, FNP-BC

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

License

95028281 Issued in CA

Practice address

625 Carnegie Dr Ste 120
San Bernardino, CA 92408-3577

Phone

(909) 383-2800

Fax

(909) 880-0439

NPI assigned

Dec 22, 2023

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Kelly Marie Smith Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mavida Care Group of New Jersey PC

  • Psychiatry Physician
  • Neptune, NJ
  • NPI 1396516977
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1703203200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1771027200000",
    "number": "1649049305",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11542 CORNELL AVE",
            "city": "RIVERSIDE",
            "state": "CA",
            "postal_code": "925076613",
            "telephone_number": "951-990-2381"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "625 CARNEGIE DR STE 120",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924083577",
            "telephone_number": "909-383-2800",
            "fax_number": "909-880-0439"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5120 Woodley Ave",
            "address_purpose": "LOCATION",
            "city": "Encino",
            "state": "CA",
            "postal_code": "914361443",
            "country_code": "US",
            "telephone_number": "628-432-7476",
            "fax_number": "888-385-7037",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MOORE",
        "first_name": "KELLY",
        "middle_name": "MARIE",
        "credential": "FNP-BC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2023-12-22",
        "last_updated": "2026-02-14",
        "certification_date": "2026-02-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "CA",
            "license": "95028281",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "SMITH",
            "middle_name": "MARIE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Damian Darryl Moore, LPT
• Deborah Linn Moore
• Donyece Moore
• Ekaterina Alexa Moore
• Elijah J Moore
• Latasha Ishawnay Moore
• Micheal Moore
• Skyler Whitney Moore
• Ujima Lanise Moore
• Maria Lourdes Mora Robledo

• Family Nurse Practitioner in San Bernardino, CA
• Providers in San Bernardino, CA by specialty
• Family Nurse Practitioner in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.