Provider Demographics
NPI:1164528774
Name:MORIARTY, KATHLEEN ANNE (CNM, PHD, CAFCI)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANNE
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:CNM, PHD, CAFCI
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-745-4525
Mailing Address - Fax:313-745-4399
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 4C
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-745-4399
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-03-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4704154951367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32150048Medicare PIN