Provider Demographics
NPI:1811227549
Name:MOON, MEGAN ELIZABETH (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:MOON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:MRS
Other - First Name:MEGAN
Other - Middle Name:ELIZABETH
Other - Last Name:SMIDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LDN
Mailing Address - Street 1:1040 1/2 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2835
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-223-9716
Practice Address - Street 1:1415 VERMONT ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3119
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-223-9716
Is Sole Proprietor?:No
Enumeration Date:2009-12-31
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005000133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3207002Medicare PIN