Provider Demographics
NPI:1629352901
Name:MOULTRIE, SUSAN MICHELLE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MICHELLE
Last Name:MOULTRIE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:MOULTRIE-JOINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:707 E OCEAN BLVD
Mailing Address - Street 2:APT 402
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5027
Mailing Address - Country:US
Mailing Address - Phone:770-712-3049
Mailing Address - Fax:
Practice Address - Street 1:12900 PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9329
Practice Address - Country:US
Practice Address - Phone:866-646-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily