Provider Demographics
NPI:1841424652
Name:MOORE, KATHRYN ANNE (LMP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:ANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 192ND AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8589
Mailing Address - Country:US
Mailing Address - Phone:253-632-2996
Mailing Address - Fax:
Practice Address - Street 1:404 E 26TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98421-1312
Practice Address - Country:US
Practice Address - Phone:253-632-2996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00024049225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist