Provider Demographics
NPI:1407217268
Name:MOON, CHRYSTAL MARIE (CHA IV)
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:F
Credentials:CHA IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7033 E TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1262
Mailing Address - Country:US
Mailing Address - Phone:907-729-6799
Mailing Address - Fax:907-729-5180
Practice Address - Street 1:100 PUMPHOUSE ROAD
Practice Address - Street 2:
Practice Address - City:TYONEK
Practice Address - State:AK
Practice Address - Zip Code:99682
Practice Address - Country:US
Practice Address - Phone:907-583-2461
Practice Address - Fax:907-583-2155
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK16-1387-IV172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker