Healthcare Provider Details

I. General information

NPI: 1003107210
Provider Name (Legal Business Name): ROXANNE MARIE MOON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CHILDRENS CIR
SANTA ROSA CA
95409-6558
US

IV. Provider business mailing address

112 CHILDRENS CIR
SANTA ROSA CA
95409-6558
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number750206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: