Provider Demographics
NPI:1952603367
Name:MOORE, HEATHER (CNM)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-294-0472
Mailing Address - Fax:
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE301
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-294-0472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169917 CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACNM0204OtherCNM LICENSE