Provider Demographics
NPI:1841412921
Name:MOSS, MONICA M
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:M
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-4743
Mailing Address - Country:US
Mailing Address - Phone:937-450-2207
Mailing Address - Fax:
Practice Address - Street 1:6100 CHANNINGWAY BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-2910
Practice Address - Country:US
Practice Address - Phone:614-751-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH114335164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2450833Medicaid