Healthcare Provider Details

I. General information

NPI: 1821958778
Provider Name (Legal Business Name): KAITLIN MOULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N MOTEL BLVD
LAS CRUCES NM
88007
US

IV. Provider business mailing address

7580 SIERRA ALTA PL
LAS CRUCES NM
88012-0710
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-3437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number66932
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: