Provider Demographics
NPI:1821055765
Name:KINARD-MOON, DANA MARIA (NP)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:MARIA
Last Name:KINARD-MOON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:DANA
Other - Middle Name:MARIA
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:770-760-9949
Mailing Address - Fax:770-760-9951
Practice Address - Street 1:1501 MILSTEAD RD NE STE 110
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3849
Practice Address - Country:US
Practice Address - Phone:770-760-9949
Practice Address - Fax:770-760-9995
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN125593363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20250I4999OtherMEDICARE PTAN
GA585149633GMedicaid