Provider Demographics
NPI:1417608548
Name:MOULTON, DARYL
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEXANDRIA
Other - Middle Name:
Other - Last Name:DRISCOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2696 DAVID ST. APT A
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AK
Mailing Address - Zip Code:99803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2075 JORDAN AVE
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-8095
Practice Address - Country:US
Practice Address - Phone:907-523-6502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker