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General NPI Number Information
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NPI Number | 1629352901
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Entity Type | Individual
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Provider Name | SUSAN MICHELLE MOULTRIE NURSE PRACTITIONER
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Gender | Female
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Dates
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Enumeration Date | 10/04/2011
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 12830 HESPERIA RD STE CDE
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City | VICTORVILLE
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State | CA
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Zip | 92395-7788
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Country | US
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Telephone | 760-684-8999
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Fax | 760-684-8111
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Provider Business Mailing Address
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Address Line | 4800 CITRUS AVE APT 5104
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City | FONTANA
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State | CA
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Zip | 92336
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Country | US
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Telephone | 770-712-3049
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 12560
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License Number State | CA
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