Healthcare Provider Details

I. General information

NPI: 1699261636
Provider Name (Legal Business Name): KELLIE JOAN WILCOX MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2614 E ST
WASHOUGAL WA
98671-1714
US

IV. Provider business mailing address

400 BALKY HILL RD
TWISP WA
98856-9762
US

V. Phone/Fax

Practice location:
  • Phone: 360-207-0134
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number60880074
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND1552
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: