Provider Demographics
NPI:1689374456
Name:MOONEYHAM, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MOONEYHAM
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 1:5310 BRANTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-6806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5060 N 19TH AVE # 317-6
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3210
Practice Address - Country:US
Practice Address - Phone:843-632-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator