Provider Demographics
NPI:1144739533
Name:MOORE, MARTHA MICHELLE
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 PAXTON DR SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3384
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:312-564-4059
Practice Address - Street 1:PIEDMONT HENRY HOSPITAL
Practice Address - Street 2:1133 EAGLES LANDING PKWY
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:678-575-7992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1035743163W00000X
GA222920363LF0000X
GARN222920163W00000X
CA95041728163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse