Healthcare Provider Details

I. General information

NPI: 1164915872
Provider Name (Legal Business Name): JOYCE HASKINS MOON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 WAINWRIGHT DR
RICHMOND VA
23225-4343
US

IV. Provider business mailing address

5524 WAINWRIGHT DR
RICHMOND VA
23225-4343
US

V. Phone/Fax

Practice location:
  • Phone: 804-627-1467
  • Fax:
Mailing address:
  • Phone: 804-627-1467
  • Fax: 804-418-3578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001177653
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: