Provider Demographics
NPI:1689059016
Name:MOON, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name: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 1:3810 WILSHIRE BLVD APT 2211
Mailing Address - Street 2:#2211
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3810 WILSHIRE BLVD APT 2211
Practice Address - Street 2:#2211
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3230
Practice Address - Country:US
Practice Address - Phone:310-729-7785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001140363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics