1215394820 NPI number — MS. INDIZO STAR MOON RN, PMHNP

Table of content: MS. INDIZO STAR MOON RN, PMHNP (NPI 1215394820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215394820 NPI number — MS. INDIZO STAR MOON RN, PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOON
Provider First Name:
INDIZO
Provider Middle Name:
STAR
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOON WELCH
Provider Other First Name:
INDIZO
Provider Other Middle Name:
STAR
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, PMHNP-BC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1215394820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2831 N YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80205-4658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-345-7393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 WELTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80205-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-443-3859
Provider Business Practice Location Address Fax Number:
983-203-9599
Provider Enumeration Date:
01/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  APN.0997135-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: RN.1627689 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2026 www.npivalidator.com