Basic Information
| Provider Information | |||||||||
| NPI: | 1316928427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOYNIHAN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 WARREN STREET, 3RD FL | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175625359 | ||||||||
| FaxNumber: | 6175625415 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 OLD WESTPORT RD | ||||||||
| Address2: | |||||||||
| City: | DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027472356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089998982 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 12/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 187390 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 0321290 | 05 | MA | MEDICAID |