Provider Demographics
NPI:1679203848
Name:MCDUFFIE-MOON, SALITHIA KEIANA
Entity Type:Individual
Prefix:
First Name:SALITHIA
Middle Name:KEIANA
Last Name:MCDUFFIE-MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CHATTAHOOCHEE CIR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-5109
Mailing Address - Country:US
Mailing Address - Phone:470-791-6969
Mailing Address - Fax:
Practice Address - Street 1:811 CHATTAHOOCHEE CIR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5109
Practice Address - Country:US
Practice Address - Phone:470-791-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACO124536OtherMASTER COSMETOLOGIST