Provider Demographics
NPI:1487360921
Name:MOE-STULL, KYLA DAWN
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:DAWN
Last Name:MOE-STULL
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 1:5 SE M L KING BLVD APT 1413
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1194
Mailing Address - Country:US
Mailing Address - Phone:720-662-3688
Mailing Address - Fax:
Practice Address - Street 1:8288 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6610
Practice Address - Country:US
Practice Address - Phone:503-477-9037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27336225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist