Healthcare Provider Details

I. General information

NPI: 1538753157
Provider Name (Legal Business Name): CAITLIN DARLENE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16821 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-0499
US

IV. Provider business mailing address

16821 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-0499
US

V. Phone/Fax

Practice location:
  • Phone: 360-207-0651
  • Fax:
Mailing address:
  • Phone: 360-207-0651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU60920869
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: