Healthcare Provider Details

I. General information

NPI: 1306994769
Provider Name (Legal Business Name): HOLLY LYNN MOEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY LYNN SLADE CNM

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAIN ST
WINTERS CA
95694-1722
US

IV. Provider business mailing address

2301 BRYCE LN
DAVIS CA
95616-6608
US

V. Phone/Fax

Practice location:
  • Phone: 530-212-1028
  • Fax:
Mailing address:
  • Phone: 530-758-3459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0002X
TaxonomyHigh-Risk Obstetric Registered Nurse
License Number285953
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number933
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: