Provider Demographics
NPI:1326037532
Name:MOFFATT, KELLY MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:MOFFATT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:427 S BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2509
Mailing Address - Country:US
Mailing Address - Phone:509-456-0107
Mailing Address - Fax:509-747-2635
Practice Address - Street 1:427 S BERNARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2509
Practice Address - Country:US
Practice Address - Phone:509-456-0701
Practice Address - Fax:509-747-2635
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA4016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist