Provider Demographics
NPI:1861812125
Name:MOON, HEIDIE (RN)
Entity type:Individual
Prefix:
First Name:HEIDIE
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 REMINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9061
Mailing Address - Country:US
Mailing Address - Phone:307-799-3019
Mailing Address - Fax:
Practice Address - Street 1:190 OVERTHRUST RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY30236163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse