Healthcare Provider Details

I. General information

NPI: 1508666801
Provider Name (Legal Business Name): MICHAELA MARIE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HAYSTACK LN LOT G2
DUBLIN GA
31021-0066
US

IV. Provider business mailing address

100 HAYSTACK LN LOT G2
DUBLIN GA
31021-0066
US

V. Phone/Fax

Practice location:
  • Phone: 478-278-7589
  • Fax:
Mailing address:
  • Phone: 478-278-7589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRNNP296510
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: