Healthcare Provider Details

I. General information

NPI: 1811391915
Provider Name (Legal Business Name): KATHYRN J MOE CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WASHINGTON AVE
DETROIT LAKES MN
56501-3905
US

IV. Provider business mailing address

1245 WASHINGTON AVE
DETROIT LAKES MN
56501-3905
US

V. Phone/Fax

Practice location:
  • Phone: 218-846-2000
  • Fax:
Mailing address:
  • Phone: 218-846-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberR 089641-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberR18777
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: