Provider Demographics
NPI:1710577168
Name:MOON, LATASHA CHRISTINE (CRANIAL PROSTHESIS)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:CHRISTINE
Last Name:MOON
Suffix:
Gender:F
Credentials:CRANIAL PROSTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9821 PARTINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6282
Mailing Address - Country:US
Mailing Address - Phone:216-798-4599
Mailing Address - Fax:
Practice Address - Street 1:1267 WILLIS ST # 200
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0400
Practice Address - Country:US
Practice Address - Phone:916-365-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty