Healthcare Provider Details

I. General information

NPI: 1003503764
Provider Name (Legal Business Name): VERONICA MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1907
US

IV. Provider business mailing address

201 CHESTNUT AVE
ALTOONA PA
16601-4927
US

V. Phone/Fax

Practice location:
  • Phone: 570-320-7690
  • Fax:
Mailing address:
  • Phone: 814-946-5411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN751757
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: