Provider Demographics
NPI:1144739533
Name:MOORE, MARTHA MICHELLE
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:MICHELLE
Last Name:MOORE
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 1:2799 LAWRENCEVILLE HWY STE 107
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2517
Mailing Address - Country:US
Mailing Address - Phone:678-739-1879
Mailing Address - Fax:
Practice Address - Street 1:2799 LAWRENCEVILLE HWY STE 107
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2517
Practice Address - Country:US
Practice Address - Phone:678-739-1879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1035743163W00000X
GARN222920163W00000X
CA95041728163W00000X
GA222920163WP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health