Provider Demographics
NPI:1447834106
Name:MOON, ANDREA M (CPM)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:MOON
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:M
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPM
Mailing Address - Street 1:123 CALLAWAY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIANVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35759-1503
Mailing Address - Country:US
Mailing Address - Phone:256-652-7968
Mailing Address - Fax:
Practice Address - Street 1:123 CALLAWAY LN
Practice Address - Street 2:
Practice Address - City:MERIDIANVILLE
Practice Address - State:AL
Practice Address - Zip Code:35759-1503
Practice Address - Country:US
Practice Address - Phone:256-652-7968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN99176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife