Provider Demographics
NPI:1760845168
Name:MOEN, MICAELA
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:MOEN
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 1:840 FREDERICA ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4704
Mailing Address - Country:US
Mailing Address - Phone:214-636-4705
Mailing Address - Fax:
Practice Address - Street 1:275 COLLIER RD NW STE 470
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1711
Practice Address - Country:US
Practice Address - Phone:404-351-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0094099208600000X
390200000X
GA96787208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program