Healthcare Provider Details

I. General information

NPI: 1710977699
Provider Name (Legal Business Name): MRS. SANDRA MARIE MOONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11065 LITTLE PATUXENT PKWY
COLUMBIA MD
21044-2998
US

IV. Provider business mailing address

7925 ANFRED DR
LAUREL MD
20723-1136
US

V. Phone/Fax

Practice location:
  • Phone: 410-730-5700
  • Fax: 410-964-3231
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR03707
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: