Provider Demographics
NPI:1982326914
Name:MOON, SULLY (IP)
Entity type:Individual
Prefix:
First Name:SULLY
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:IP
Other - Prefix:
Other - First Name:JARETH
Other - Middle Name:MICHEAL
Other - Last Name:HEILMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1410 N CAUFIELD CT
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99016-9433
Mailing Address - Country:US
Mailing Address - Phone:360-525-5996
Mailing Address - Fax:
Practice Address - Street 1:1410 N CAUFIELD CT
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99016-9433
Practice Address - Country:US
Practice Address - Phone:360-525-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider