Provider Demographics
NPI:1689210569
Name:MOULTON, MICHELLE MARIE (RN,CMHN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:RN,CMHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-1437
Mailing Address - Country:US
Mailing Address - Phone:315-568-9412
Mailing Address - Fax:315-588-2441
Practice Address - Street 1:12 N PARK ST
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-1437
Practice Address - Country:US
Practice Address - Phone:315-568-9412
Practice Address - Fax:315-588-2441
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY551539163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health