Provider Demographics
NPI:1417979675
Name:MOULTON, CHARLOTTE ELISE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:ELISE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8837 SE TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1738
Mailing Address - Country:US
Mailing Address - Phone:954-655-2574
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:MAILCODE UHS-2
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-4910
Practice Address - Fax:503-494-8368
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200660031CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered