Provider Demographics
NPI:1073336202
Name:MOREAU, MICHAELLE
Entity type:Individual
Prefix:
First Name:MICHAELLE
Middle Name:
Last Name:MOREAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 SCRANTON AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3336
Mailing Address - Country:US
Mailing Address - Phone:646-458-1337
Mailing Address - Fax:
Practice Address - Street 1:416 SCRANTON AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3336
Practice Address - Country:US
Practice Address - Phone:646-458-1337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist