Provider Demographics
NPI:1518268077
Name:MOON, SHERRY (CD-N)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:CD-N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 BOICES LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1083
Mailing Address - Country:US
Mailing Address - Phone:845-382-1899
Mailing Address - Fax:
Practice Address - Street 1:521 BOICES LN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1083
Practice Address - Country:US
Practice Address - Phone:845-382-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004598133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist