Healthcare Provider Details

I. General information

NPI: 1578904496
Provider Name (Legal Business Name): MEGAN ELIZABETH MOORE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16723 23RD AVE SE
BOTHELL WA
98012-6017
US

IV. Provider business mailing address

16723 23RD AVE SE
BOTHELL WA
98012-6017
US

V. Phone/Fax

Practice location:
  • Phone: 206-484-2283
  • Fax:
Mailing address:
  • Phone: 206-484-2283
  • Fax: 206-312-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60163114
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: