Healthcare Provider Details

I. General information

NPI: 1508690603
Provider Name (Legal Business Name): BONNIE LYNN MOON DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 GREEN VALLEY CIR STE 405
CULVER CITY CA
90230-6971
US

IV. Provider business mailing address

100 CORPORATE POINTE STE 270
CULVER CITY CA
90230-8735
US

V. Phone/Fax

Practice location:
  • Phone: 424-266-7474
  • Fax:
Mailing address:
  • Phone: 424-266-7474
  • Fax: 310-596-8268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: