Provider Demographics
NPI:1154559425
Name:MOONEY, TINA LYNN (FPN,C)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LYNN
Last Name:MOONEY
Suffix:
Gender:F
Credentials:FPN,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10012 KENNERLY RD STE 403
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-880-6676
Mailing Address - Fax:314-842-4372
Practice Address - Street 1:10012 KENNERLY RD STE 403
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-880-6676
Practice Address - Fax:314-842-4372
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF0808214363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily