Provider Demographics
NPI:1063819043
Name:MOULTON, KATELYN (ARNP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HARVARD AVE E UNIT 403
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-6043
Mailing Address - Country:US
Mailing Address - Phone:301-442-1376
Mailing Address - Fax:
Practice Address - Street 1:1103 CORTELYOU RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-5303
Practice Address - Country:US
Practice Address - Phone:718-282-0170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382496363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics