Healthcare Provider Details

I. General information

NPI: 1952879413
Provider Name (Legal Business Name): MARTHA MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 07/27/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 POST ALY
SEATTLE WA
98101-1074
US

IV. Provider business mailing address

1200 12TH AVE S STE 901
SEATTLE WA
98144-2712
US

V. Phone/Fax

Practice location:
  • Phone: 206-728-4143
  • Fax:
Mailing address:
  • Phone: 206-548-3114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60912342
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: