Provider Demographics
NPI:1659402923
Name:MOORE, SUSAN KELLY (LAC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KELLY
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 NW MARKET ST
Mailing Address - Street 2:SUITE 408
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4030
Mailing Address - Country:US
Mailing Address - Phone:206-789-8843
Mailing Address - Fax:206-297-6118
Practice Address - Street 1:2208 NW MARKET ST
Practice Address - Street 2:SUITE 408
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4030
Practice Address - Country:US
Practice Address - Phone:206-789-8843
Practice Address - Fax:206-297-6118
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 347171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist