Provider Demographics
NPI:1245937036
Name:ALAN, MOONLIGHT
Entity type:Individual
Prefix:
First Name:MOONLIGHT
Middle Name:
Last Name:ALAN
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 1:945 N SERRANO AVE APT 113
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-3274
Mailing Address - Country:US
Mailing Address - Phone:213-422-9126
Mailing Address - Fax:
Practice Address - Street 1:3808 W RIVERSIDE DR STE 407
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-5301
Practice Address - Country:US
Practice Address - Phone:213-218-9245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF08220387OtherOTHER INSURANCE