Provider Demographics
NPI:1801328372
Name:MOON, SHIRLEY A (LPN)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:A
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 1:601 S EDWIN MOSES BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-716-1331
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:937-716-1331
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH148589M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse