Provider Demographics
NPI:1477112274
Name:MOON, KIERSTEN TAYLOR (OD)
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:TAYLOR
Last Name:MOON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 COOSA ST E
Mailing Address - Street 2:STE A
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-2154
Mailing Address - Country:US
Mailing Address - Phone:919-614-0268
Mailing Address - Fax:
Practice Address - Street 1:109 COOSA ST E STE A
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2154
Practice Address - Country:US
Practice Address - Phone:256-362-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-E22152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist