Provider Demographics
NPI:1407448384
Name:MOORE, KATHRYN K (NP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 RIPPLEWATER DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2474
Mailing Address - Country:US
Mailing Address - Phone:740-703-7260
Mailing Address - Fax:
Practice Address - Street 1:400 S 43RD ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5714
Practice Address - Country:US
Practice Address - Phone:425-228-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA104422061363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care