Basic Information
| Provider Information | |||||||||
| NPI: | 1326245598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS-MOON | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 SANSOM ST. | ||||||||
| Address2: | 239 THOMPSON BLDG. | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556844 | ||||||||
| FaxNumber: | 2159236225 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 SANSOM ST. | ||||||||
| Address2: | 239 THOMPSON BLDG. | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556844 | ||||||||
| FaxNumber: | 2159236225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 02/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP004940B | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | SP004940B | 01 | PA | CRNP LICENSE | OTHER | MD0934681 | 01 | PA | DEA LICENSE | OTHER |