Provider Demographics
NPI:1942434352
Name:MOEN, RICHELLE LEIGH
Entity Type:Individual
Prefix:
First Name:RICHELLE
Middle Name:LEIGH
Last Name:MOEN
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 1:105 GRANT CIR
Mailing Address - Street 2:SUITE 133
Mailing Address - City:OFFUTT A F B
Mailing Address - State:NE
Mailing Address - Zip Code:68113-4041
Mailing Address - Country:US
Mailing Address - Phone:402-294-7346
Mailing Address - Fax:
Practice Address - Street 1:105 GRANT CIR
Practice Address - Street 2:SUITE 133
Practice Address - City:OFFUTT A F B
Practice Address - State:NE
Practice Address - Zip Code:68113-4041
Practice Address - Country:US
Practice Address - Phone:402-294-7346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians