Healthcare Provider Details

I. General information

NPI: 1164528774
Provider Name (Legal Business Name): KATHLEEN ANNE MORIARTY CNM, PHD, CAFCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 03/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST SUITE 4C
DETROIT MI
48201-2153
US

IV. Provider business mailing address

1560 E MAPLE RD SUITE 400-CREDENTIALING
TROY MI
48083-1138
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4525
  • Fax: 313-745-4399
Mailing address:
  • Phone: 313-745-4525
  • Fax: 313-745-4399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number4704154951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: