Provider Demographics
NPI:1457238685
Name:MOE, MADELEINE MARIE
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:MARIE
Last Name:MOE
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 1:4095 141ST CT W
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-4100
Mailing Address - Country:US
Mailing Address - Phone:651-485-2422
Mailing Address - Fax:
Practice Address - Street 1:3501 ALDRICH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-4149
Practice Address - Country:US
Practice Address - Phone:612-721-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker