Provider Demographics
NPI:1053164988
Name:MOMOSE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MOMOSE
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 1:115 BRAMBLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LEWISBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:17339-9536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 BRAMBLEWOOD LN
Practice Address - Street 2:
Practice Address - City:LEWISBERRY
Practice Address - State:PA
Practice Address - Zip Code:17339-9536
Practice Address - Country:US
Practice Address - Phone:717-614-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010353111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor