Healthcare Provider Details

I. General information

NPI: 1700359817
Provider Name (Legal Business Name): LEAH SONG MOON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 HOOKS ST
CLERMONT FL
34711-3551
US

IV. Provider business mailing address

16399 SILVER BROOK WAY
WINTER GARDEN FL
34787-8577
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11000464
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: