Provider Demographics
NPI:1013025501
Name:MOENS, KELLY E (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:MOENS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12606 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-3421
Mailing Address - Country:US
Mailing Address - Phone:509-838-6709
Mailing Address - Fax:509-835-4058
Practice Address - Street 1:12606 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-3421
Practice Address - Country:US
Practice Address - Phone:509-838-6709
Practice Address - Fax:509-835-4058
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2009-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001703367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004376000Medicaid
WA244046OtherDEPT OF LABOR AND INDUSTRIES
WA9647041Medicaid
ID8856706Medicare PIN
WAG8876756Medicare PIN