Healthcare Provider Details

I. General information

NPI: 1619798550
Provider Name (Legal Business Name): KATHLEEN T. MOEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 ROBINSON RD
BOW NH
03304-3820
US

IV. Provider business mailing address

86 ROBINSON RD
BOW NH
03304-3820
US

V. Phone/Fax

Practice location:
  • Phone: 603-491-7468
  • Fax:
Mailing address:
  • Phone: 603-491-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number075986-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: