Healthcare Provider Details

I. General information

NPI: 1689210569
Provider Name (Legal Business Name): MICHELLE MARIE MOULTON RN,CMHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N PARK ST
SENECA FALLS NY
13148-1437
US

IV. Provider business mailing address

12 N PARK ST
SENECA FALLS NY
13148-1437
US

V. Phone/Fax

Practice location:
  • Phone: 315-568-9412
  • Fax: 315-588-2441
Mailing address:
  • Phone: 315-568-9412
  • Fax: 315-588-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number551539
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: