Provider Demographics
NPI:1013296128
Name:HARRIS-MOULTON, MELINDA ANNE (MSN, ARNP, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:ANNE
Last Name:HARRIS-MOULTON
Suffix:
Gender:F
Credentials:MSN, ARNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 89
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0089
Mailing Address - Country:US
Mailing Address - Phone:360-740-0888
Mailing Address - Fax:360-740-0555
Practice Address - Street 1:5201 DOLPHIN LN NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-9226
Practice Address - Country:US
Practice Address - Phone:360-866-8143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP 60238471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034229Medicaid