Provider Demographics
NPI:1841204385
Name:MOON, WAN HEE Y (PH D, RD)
Entity Type:Individual
Prefix:DR
First Name:WAN HEE
Middle Name:Y
Last Name:MOON
Suffix:
Gender:F
Credentials:PH D, RD
Other - Prefix:DR
Other - First Name:JENNIE
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PH D, RD
Mailing Address - Street 1:1720 TERMINO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2104
Mailing Address - Country:US
Mailing Address - Phone:562-498-1000
Mailing Address - Fax:562-494-0547
Practice Address - Street 1:1720 TERMINO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2104
Practice Address - Country:US
Practice Address - Phone:562-498-1000
Practice Address - Fax:562-494-0547
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00370020133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMNT370020Medicare ID - Type UnspecifiedREGISTERED DIETITIAN (RD)