Provider Demographics
NPI:1811668411
Name:MORIARTY, JUSTINE NICA (IDHS)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:NICA
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1742
Mailing Address - Country:US
Mailing Address - Phone:616-850-2520
Mailing Address - Fax:616-850-2521
Practice Address - Street 1:650 S HARBOR DR
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1742
Practice Address - Country:US
Practice Address - Phone:616-850-2520
Practice Address - Fax:616-850-2521
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians