Healthcare Provider Details

I. General information

NPI: 1003066259
Provider Name (Legal Business Name): LAURA DIANE MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA DIANE STARCHER

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

110 ROANE ST
CHARLESTON WV
25302-2334
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4111
  • Fax:
Mailing address:
  • Phone: 304-344-0096
  • Fax: 304-342-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number55025
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number79610
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26055
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: