Healthcare Provider Details

I. General information

NPI: 1154280279
Provider Name (Legal Business Name): ATHENA MARIE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SE SUNSET AVE
CASCADE LOCKS OR
97014-5011
US

IV. Provider business mailing address

PO BOX 323
CASCADE LOCKS OR
97014-0323
US

V. Phone/Fax

Practice location:
  • Phone: 541-400-7285
  • Fax:
Mailing address:
  • Phone: 541-400-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number10272869
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: