Provider Demographics
NPI:1922879618
Name:MOON, HEATHER N (LPN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:N
Last Name:MOON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SYMMES RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-1844
Mailing Address - Country:US
Mailing Address - Phone:513-645-4578
Mailing Address - Fax:513-883-1546
Practice Address - Street 1:515 DAYTON ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-3455
Practice Address - Country:US
Practice Address - Phone:513-868-7654
Practice Address - Fax:513-737-0026
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.167003.MED-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse