Provider Demographics
NPI:1417220153
Name:MOON, HEATHER MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:MOON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5091 TODD RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5076
Mailing Address - Country:US
Mailing Address - Phone:937-790-6577
Mailing Address - Fax:
Practice Address - Street 1:5091 TODD RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-5076
Practice Address - Country:US
Practice Address - Phone:937-790-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN104587164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN104587OtherBOARD OF NURSING