Provider Demographics
NPI:1649206764
Name:MOEN, KATHLEEN YANELLI (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:YANELLI
Last Name:MOEN
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 1:1101 MADISON ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1306
Mailing Address - Country:US
Mailing Address - Phone:206-215-2700
Mailing Address - Fax:206-215-2702
Practice Address - Street 1:1101 MADISON ST
Practice Address - Street 2:SUITE 800
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1306
Practice Address - Country:US
Practice Address - Phone:206-215-2700
Practice Address - Fax:206-215-2702
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60278954207XP3100X
NH10368207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30011560Medicaid
VT0RE4880Medicaid
NHRE4880Medicare PIN
VT0RE4880Medicaid
NH30011560Medicaid