Provider Demographics
NPI:1306994769
Name:MOEN, HOLLY LYNN (CNM)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:MOEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:LYNN
Other - Last Name:SLADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:2301 BRYCE LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-6608
Mailing Address - Country:US
Mailing Address - Phone:530-758-3459
Mailing Address - Fax:
Practice Address - Street 1:23 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:CA
Practice Address - Zip Code:95694-1722
Practice Address - Country:US
Practice Address - Phone:530-212-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA285953163WX0002X
CA933367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk