Provider Demographics
NPI:1003066259
Name:MOON, LAURA DIANE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DIANE
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:DIANE
Other - Last Name:STARCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 ROANE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2334
Mailing Address - Country:US
Mailing Address - Phone:304-344-0096
Mailing Address - Fax:304-342-4725
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV55025163W00000X
WV79610367500000X
SC26055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse