Provider Demographics
NPI:1114180171
Name:MOON, JINA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:JINA
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66505-0747
Mailing Address - Country:US
Mailing Address - Phone:785-587-4344
Mailing Address - Fax:785-587-4377
Practice Address - Street 1:1558 HAYES DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5068
Practice Address - Country:US
Practice Address - Phone:785-587-4333
Practice Address - Fax:785-587-4377
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-98353-052163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse