Healthcare Provider Details

I. General information

NPI: 1306038955
Provider Name (Legal Business Name): STEPHANIE M MOON APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 JUSTISON ST
WILMINGTON DE
19801-5162
US

IV. Provider business mailing address

47 PARISH LN
WILLINGBORO NJ
08046-2707
US

V. Phone/Fax

Practice location:
  • Phone: 302-660-3378
  • Fax:
Mailing address:
  • Phone: 609-234-9665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00139400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: