Provider Demographics
NPI:1407482698
Name:MOEN, ERIN (PTA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:MOEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:NALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28175 AMARYLISS WAY
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-3407
Mailing Address - Country:US
Mailing Address - Phone:503-928-1554
Mailing Address - Fax:
Practice Address - Street 1:1350 E DEVONSHIRE AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-8629
Practice Address - Country:US
Practice Address - Phone:951-925-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA50373225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant