Provider Demographics
NPI:1043393655
Name:MOONEY, KATHLEEN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:MOONEY
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 1:9300 SE 91ST AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3749
Mailing Address - Country:US
Mailing Address - Phone:503-261-1171
Mailing Address - Fax:
Practice Address - Street 1:9300 SE 91ST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3749
Practice Address - Country:US
Practice Address - Phone:503-261-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038960208000000X
ORMD27072208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8257081Medicaid
WAH28411Medicare UPIN
WAAB23581Medicare ID - Type UnspecifiedUW PHYSICIANS