Basic Information
| Provider Information | |||||||||
| NPI: | 1093992034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | JILL | ||||||||
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| Credential: | PNP, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 YORK AVE | ||||||||
| Address2: | 9TH FLOOR DEPARTMENT OF PEDIATRICS | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100656007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126392000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1275 YORK AVE | ||||||||
| Address2: | 9TH FLOOR DEPARTMENT OF PEDIATRICS | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100656007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126392000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 541901 | NY | N | Nursing Service Providers | Registered Nurse | 363LP0200X | 381942 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.