Provider Demographics
NPI:1568190197
Name:MOULTON, WANDA SUE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:SUE
Last Name:MOULTON
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 1:4234 SUNNILAND ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-1817
Mailing Address - Country:US
Mailing Address - Phone:941-921-3801
Mailing Address - Fax:
Practice Address - Street 1:4234 SUNNILAND ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1817
Practice Address - Country:US
Practice Address - Phone:941-921-3801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8267164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse