Provider Demographics
NPI:1588713861
Name:MOONEY, SANDRA (MS, ARNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MOONEY
Suffix:
Gender:F
Credentials:MS, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-2830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 S ALEXANDER ST
Practice Address - Street 2:SUITE 6
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-8400
Practice Address - Country:US
Practice Address - Phone:813-719-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1216832101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP 1216832OtherARNP LICENSE
FLY4142Medicare UPIN