Healthcare Provider Details

I. General information

NPI: 1144739533
Provider Name (Legal Business Name): MARTHA MICHELLE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 LAWRENCEVILLE HWY STE 107
DECATUR GA
30033-2517
US

IV. Provider business mailing address

2799 LAWRENCEVILLE HWY STE 107
DECATUR GA
30033-2517
US

V. Phone/Fax

Practice location:
  • Phone: 678-739-1879
  • Fax:
Mailing address:
  • Phone: 678-739-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1035743
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN222920
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95041728
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number222920
License Number StateGA
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number222920
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: