Healthcare Provider Details

I. General information

NPI: 1265004063
Provider Name (Legal Business Name): JACQUELINE MOYLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3313 CHENU AVE
SACRAMENTO CA
95821-6205
US

IV. Provider business mailing address

3313 CHENU AVE
SACRAMENTO CA
95821-6205
US

V. Phone/Fax

Practice location:
  • Phone: 916-505-2303
  • Fax:
Mailing address:
  • Phone: 916-505-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95017499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: