Healthcare Provider Details

I. General information

NPI: 1952573289
Provider Name (Legal Business Name): SARAH MOON THELEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH MARIE MOON

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 COLLEGE ST W
FAYETTEVILLE TN
37334-2911
US

IV. Provider business mailing address

PO BOX 38
FAYETTEVILLE TN
37334-0038
US

V. Phone/Fax

Practice location:
  • Phone: 931-227-4984
  • Fax: 931-227-4985
Mailing address:
  • Phone: 931-227-4984
  • Fax: 931-227-4985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD46417
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: