Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | MID-46 | ID |
NPI | 1154666055 |
---|---|
Provider Name | Ms. Violet Leona Moon |
First Address | Boise, ID 83702-5989 |
Second Address | Boise, ID 83702-5989 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/12/2012 |
Last Update Date | 03/12/2012 |