Provider Demographics
NPI:1306264718
Name:MOON, STACY (LAC OSOM)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:LAC OSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149-15 25 AVE #1A
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357
Mailing Address - Country:US
Mailing Address - Phone:347-337-9676
Mailing Address - Fax:
Practice Address - Street 1:149-15 25 AVE #1A
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357
Practice Address - Country:US
Practice Address - Phone:347-337-9676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist