Provider Demographics
NPI:1992043897
Name:MOULTON, TRACIE (NP)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 ROUTE 130
Mailing Address - Street 2:P O BOX 549
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644-1402
Mailing Address - Country:US
Mailing Address - Phone:508-477-5306
Mailing Address - Fax:508-477-0297
Practice Address - Street 1:55 ROUTE 130
Practice Address - Street 2:
Practice Address - City:FORESTDALE
Practice Address - State:MA
Practice Address - Zip Code:02644-1402
Practice Address - Country:US
Practice Address - Phone:508-477-5306
Practice Address - Fax:508-477-0297
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170590363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics