MEDICARE: MS. INDIZO STAR MOON RN, PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APN.0997135-NP	CO
2	163W00000X	Registered Nurse	RN.1627689	CO

General Provider Information

NPI Number	:	1215394820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. INDIZO STAR MOON RN, PMHNP

Provider Business Mailing Address
First Line	:	2831 N YORK ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-4658
Country	:	US
Telephone Number	:	808-345-7393
Fax Number	:

Provider Business Practice Location Address
First Line	:	2850 WELTON ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80205-3020
Country	:	US
Telephone Number	:	720-443-3859
Fax Number	:	983-203-9599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2016
Last Update Date	:	06/03/2026

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