Healthcare Provider Details

I. General information

NPI: 1902315682
Provider Name (Legal Business Name): SARAH AAN MOORE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH AAN PROVENCE N/A

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6426 LOMBARD AVE
EVERETT WA
98203-4814
US

IV. Provider business mailing address

6426 LOMBARD AVE
EVERETT WA
98203-4814
US

V. Phone/Fax

Practice location:
  • Phone: 206-234-5104
  • Fax:
Mailing address:
  • Phone: 206-234-5104
  • Fax: 206-656-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60808218
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: