Provider Demographics
NPI:1790724011
Name:MOON, ALICE GAIL (MSRD, PAC)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:GAIL
Last Name:MOON
Suffix:
Gender:F
Credentials:MSRD, PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20010 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1408
Mailing Address - Country:US
Mailing Address - Phone:248-471-7171
Mailing Address - Fax:248-471-1212
Practice Address - Street 1:20010 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1408
Practice Address - Country:US
Practice Address - Phone:248-471-7171
Practice Address - Fax:248-471-1212
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI577469133V00000X
MI5601002478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant