Provider Demographics
NPI:1831583012
Name:MOULTON, JENNA MARIE (CPNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:HULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:241 N TERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-5229
Mailing Address - Country:US
Mailing Address - Phone:716-983-9603
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4898
Practice Address - Country:US
Practice Address - Phone:212-606-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382529363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics