MEDICARE: LAURA E MOON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN144320	GA

General Provider Information

NPI Number	:	1265906226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA E MOON NP

Provider Business Mailing Address
First Line	:	PO BOX 48089
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30604-8089
Country	:	US
Telephone Number	:	706-389-3740
Fax Number	:	706-389-3951

Provider Business Practice Location Address
First Line	:	1021 JAMESTOWN BLVD STE 215
Second Line	:
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-4176
Country	:	US
Telephone Number	:	706-389-2273
Fax Number	:	706-389-2298

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	06/29/2021

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Directions to “ LAURA E MOON NP” Practice Location

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