Provider Demographics
NPI:1902315682
Name:MOORE, SARAH AAN (RD)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:AAN
Last Name:MOORE
Suffix:
Gender:
Credentials:RD
Other - Prefix:MISS
Other - First Name:SARAH
Other - Middle Name:AAN
Other - Last Name:PROVENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:N/A
Mailing Address - Street 1:6426 LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-4814
Mailing Address - Country:US
Mailing Address - Phone:206-234-5104
Mailing Address - Fax:206-656-5583
Practice Address - Street 1:6426 LOMBARD AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-4814
Practice Address - Country:US
Practice Address - Phone:206-234-5104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60808218133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1902315682Medicaid