Basic Information
| Provider Information | |||||||||
| NPI: | 1417050386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUSSA | ||||||||
| FirstName: | HALEEM | ||||||||
| MiddleName: | JACOB | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 481 SW RIDGEVIEW LANE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 32024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867583076 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 SOUTH MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867546348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | R14403 | ND | Y | Nursing Service Providers | Registered Nurse | Medical-Surgical |
ID Information
| ID | Type | State | Issuer | Description | R14403 | 01 | ND | RN, APRN, CRNA | OTHER |