Provider Demographics
NPI:1336673946
Name:MOON, SAVANNAH VAUGHN (NP)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:VAUGHN
Last Name:MOON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WETUMPKA
Mailing Address - State:AL
Mailing Address - Zip Code:36092-0003
Mailing Address - Country:US
Mailing Address - Phone:334-280-0620
Mailing Address - Fax:334-280-0625
Practice Address - Street 1:1210 7TH ST S
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-3724
Practice Address - Country:US
Practice Address - Phone:334-514-3848
Practice Address - Fax:334-280-0625
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140246363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
511-91222OtherBCBS