Basic Information
| Provider Information | |||||||||
| NPI: | 1811227549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LDN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMIDDY | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD LDN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 1/2 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623012835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172239716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1415 VERMONT ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623013119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172238400 | ||||||||
| FaxNumber: | 2172239716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2009 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
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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 | 133VN1006X | 164005000 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
No ID Information.