Provider Demographics
NPI:1467789990
Name:TANNENBAUM, MOIRA ALLISON (CNM, RN)
Entity Type:Individual
Prefix:MS
First Name:MOIRA
Middle Name:ALLISON
Last Name:TANNENBAUM
Suffix:
Gender:F
Credentials:CNM, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3185 OAKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6667
Mailing Address - Country:US
Mailing Address - Phone:734-975-1402
Mailing Address - Fax:
Practice Address - Street 1:3185 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-6667
Practice Address - Country:US
Practice Address - Phone:734-975-1402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2013-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704216874163WL0100X, 163WN0003X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WN0003XNursing Service ProvidersRegistered NurseNeonatal, Low-Risk
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810025733Medicaid
WVQ43188EMedicare PIN
WV3810025733Medicaid
WVQ43188DMedicare PIN
WVQ43188AMedicare PIN
WVQ43188BMedicare PIN