Provider Demographics
NPI:1104803998
Name:MOULTON, ANN MICHELLE (FNP)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:MICHELLE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:ANN
Other - Middle Name:MICHELLE
Other - Last Name:SACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-0497
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:
Practice Address - Street 1:2015 RANDOLPH RD
Practice Address - Street 2:SUITE 208
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1128
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2806521AMedicare ID - Type Unspecified
NCQ48718Medicare UPIN