Healthcare Provider Details

I. General information

NPI: 1497094692
Provider Name (Legal Business Name): MARILYN MOAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2513 SUN SEEKER CT
LEXINGTON KY
40503-2980
US

IV. Provider business mailing address

2513 SUN SEEKER CT
LEXINGTON KY
40503-2980
US

V. Phone/Fax

Practice location:
  • Phone: 859-523-4442
  • Fax:
Mailing address:
  • Phone: 859-523-4442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number753250
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number1124028
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: