Provider Demographics
NPI:1356561492
Name:MOORE, KATHLEEN P (LMP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 JACKSON HWY
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4410
Mailing Address - Country:US
Mailing Address - Phone:360-748-0355
Mailing Address - Fax:
Practice Address - Street 1:1637 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3826
Practice Address - Country:US
Practice Address - Phone:360-748-9827
Practice Address - Fax:360-748-7353
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist