Provider Demographics
NPI:1407217268
Name:MOON, CHRYSTAL MARIE (CHA/P)
Entity Type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:F
Credentials:CHA/P
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 82068
Mailing Address - Street 2:
Mailing Address - City:TYONEK
Mailing Address - State:AK
Mailing Address - Zip Code:99682-0068
Mailing Address - Country:US
Mailing Address - Phone:907-583-2461
Mailing Address - Fax:907-583-2155
Practice Address - Street 1:100 PUMPHOUSE ROAD
Practice Address - Street 2:
Practice Address - City:TYONEK
Practice Address - State:AK
Practice Address - Zip Code:99682
Practice Address - Country:US
Practice Address - Phone:907-583-2461
Practice Address - Fax:907-583-2155
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK161387172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker