Provider Demographics
NPI:1073104550
Name:MOULTON, JILLIAN CASSIDY (MSN, RN,)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:CASSIDY
Last Name:MOULTON
Suffix:
Gender:F
Credentials:MSN, RN,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 ELEANOR AVE
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-6613
Mailing Address - Country:US
Mailing Address - Phone:802-825-5455
Mailing Address - Fax:
Practice Address - Street 1:73 ELEANOR AVE
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:ME
Practice Address - Zip Code:04084-6613
Practice Address - Country:US
Practice Address - Phone:802-825-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN78403163W00000X
CORN1647168163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse