Provider Demographics
NPI:1700359817
Name:MOON, LEAH SONG (FNP)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:SONG
Last Name:MOON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 BELLA LAGO DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-4635
Mailing Address - Country:US
Mailing Address - Phone:702-899-0595
Mailing Address - Fax:702-977-1496
Practice Address - Street 1:1775 HOOKS ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3551
Practice Address - Country:US
Practice Address - Phone:872-231-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily