Provider Demographics
NPI:1861609414
Name:MOON LABRIOLA, SUSAN K (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:K
Last Name:MOON LABRIOLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-543-5577
Mailing Address - Fax:805-595-3231
Practice Address - Street 1:715 TANK FARM ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7068
Practice Address - Country:US
Practice Address - Phone:805-543-5577
Practice Address - Fax:805-595-3231
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15865364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology