Provider Demographics
NPI:1629473368
Name:MOON, AMY (RN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8931 STATE ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:WEST CHAZY
Mailing Address - State:NY
Mailing Address - Zip Code:12992-3131
Mailing Address - Country:US
Mailing Address - Phone:585-749-7928
Mailing Address - Fax:
Practice Address - Street 1:8931 STATE ROUTE 22
Practice Address - Street 2:
Practice Address - City:WEST CHAZY
Practice Address - State:NY
Practice Address - Zip Code:12992-3131
Practice Address - Country:US
Practice Address - Phone:585-749-7928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY692295163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health