Provider Demographics
NPI:1710491501
Name:MOULTON, BRITTANY NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:NICOLE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:NICOLE
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVENUE
Mailing Address - Street 2:WILSON BUILDING
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-254-1850
Mailing Address - Fax:585-254-0549
Practice Address - Street 1:1425 PORTLAND AVENUE
Practice Address - Street 2:WILSON BUILDING
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-254-1850
Practice Address - Fax:585-254-0549
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342318363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05005014Medicaid