Provider Demographics
NPI:1841337383
Name:MOULTON, SUSAN L (WHNP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:L
Last Name:MOULTON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2284 S BALLENGER HWY
Mailing Address - Street 2:SUITE H
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-3446
Mailing Address - Country:US
Mailing Address - Phone:810-233-5211
Mailing Address - Fax:
Practice Address - Street 1:2284 S BALLENGER HWY
Practice Address - Street 2:SUITE H
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3446
Practice Address - Country:US
Practice Address - Phone:810-233-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704104617363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4416010Medicaid
MIOM32030OtherMEDICARE GROUP
MI5008767180OtherBCBS ID
MI4416010Medicaid
MIM 32030073Medicare PIN
MI4416010Medicaid