Basic Information
| Provider Information | |||||||||
| NPI: | 1487321121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9221 LAWFORD WAY APT 310 | ||||||||
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| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373635007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233940621 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2333 MCCALLIE AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374043258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236986061 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2021 | ||||||||
| LastUpdateDate: | 08/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 30066 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.