Provider Demographics
NPI:1508690603
Name:MOON, BONNIE LYNN (DNP)
Entity type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:LYNN
Last Name:MOON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1538 N MARTEL AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-8610
Mailing Address - Country:US
Mailing Address - Phone:818-370-8674
Mailing Address - Fax:
Practice Address - Street 1:530 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3723
Practice Address - Country:US
Practice Address - Phone:213-747-2626
Practice Address - Fax:213-749-7500
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95031601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily