Provider Demographics
NPI:1710040761
Name:MOULTON, SCOTT (FNP, RN, DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:MOULTON
Suffix:
Gender:M
Credentials:FNP, RN, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 N REO ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-1013
Mailing Address - Country:US
Mailing Address - Phone:813-549-2134
Mailing Address - Fax:
Practice Address - Street 1:400 W ARBROOK BLVD STE 120
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3175
Practice Address - Country:US
Practice Address - Phone:817-522-3672
Practice Address - Fax:817-803-4125
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6383111N00000X
TX774434363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No111N00000XChiropractic ProvidersChiropractor