Provider Demographics
NPI:1942835772
Name:MOON, MARLIS
Entity Type:Individual
Prefix:
First Name:MARLIS
Middle Name:
Last Name:MOON
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 1:2106 OBERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-4536
Mailing Address - Country:US
Mailing Address - Phone:440-370-5803
Mailing Address - Fax:
Practice Address - Street 1:2106 OBERLIN AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4536
Practice Address - Country:US
Practice Address - Phone:440-370-5803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide