Provider Demographics
NPI:1194951137
Name:MOONAN, SANDRA L (LMT)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:MOONAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8333 W MCNAB RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3242
Mailing Address - Country:US
Mailing Address - Phone:954-934-3209
Mailing Address - Fax:
Practice Address - Street 1:8333 W MCNAB RD
Practice Address - Street 2:SUITE 205
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3242
Practice Address - Country:US
Practice Address - Phone:954-934-3209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA56294174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist