Basic Information
Provider Information | |||||||||
NPI: | 1023364106 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOEN | ||||||||
FirstName: | KATRINA | ||||||||
MiddleName: | EILEEN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WALZ | ||||||||
OtherFirstName: | KATRINA | ||||||||
OtherMiddleName: | EILEEN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 700 NE 87TH AVE | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986641913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603973352 | ||||||||
FaxNumber: | 3606041771 | ||||||||
Practice Location | |||||||||
Address1: | 291 C ST UNIT 110 | ||||||||
Address2: |   | ||||||||
City: | WASHOUGAL | ||||||||
State: | WA | ||||||||
PostalCode: | 98671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608822778 | ||||||||
FaxNumber: | 3606041644 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2012 | ||||||||
LastUpdateDate: | 07/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 60301097 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 201250106NP | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.