=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306994769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY LYNN MOEN CNM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 03/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 MAIN ST
-----------------------------------------------------
City | WINTERS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95694-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-212-1028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 BRYCE LN
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95616-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-758-3459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WX0002X
-----------------------------------------------------
Taxonomy Name | High-Risk Obstetric Registered Nurse
-----------------------------------------------------
License Number | 285953
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 933
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------