Provider Demographics
NPI:1912038555
Name:MOON, JULIA L (COTA,L)
Entity Type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:L
Last Name:MOON
Suffix:
Gender:F
Credentials:COTA,L
Other - Prefix:MISS
Other - First Name:JULIA
Other - Middle Name:L
Other - Last Name:KRIZAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA,L
Mailing Address - Street 1:4435 W 152ND CT
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66224-9782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10300 W 103RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-2642
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-00225174400000X
MO2002030254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS18-00225OtherSTATE LICENSE NUMBER
MO2002030254OtherSTATE LICENSE NUMBER