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General NPI Number Information
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NPI Number | 1295417186
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Entity Type | Organization
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Legal Business Name | HEADSPACE PARKING LOT PLLC
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Dates
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Enumeration Date | 08/01/2023
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 76 SUND RD
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City | ELMA
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State | WA
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Zip | 98541-9119
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Country | US
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Telephone | 360-929-0022
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Fax |
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Provider Business Mailing Address
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Address Line | 76 SUND RD
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City | ELMA
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State | WA
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Zip | 98541-9119
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Country | US
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Telephone | 360-929-0022
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Fax |
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Authorized Official
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Title or Position | PMHNP
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Name | CHRYSTAL G MOORE
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Credential | ARNP
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Telephone | 757-323-9104
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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