Provider Demographics
NPI:1538753157
Name:MOORE, CAITLIN DARLENE
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:DARLENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16821 SE MCGILLIVRAY BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-0499
Mailing Address - Country:US
Mailing Address - Phone:360-207-0651
Mailing Address - Fax:
Practice Address - Street 1:16821 SE MCGILLIVRAY BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-0499
Practice Address - Country:US
Practice Address - Phone:360-207-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU60920869133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist