Provider Demographics
NPI:1649490459
Name:MOULYN, CRISSIE LEE (FNP)
Entity type:Individual
Prefix:MRS
First Name:CRISSIE
Middle Name:LEE
Last Name:MOULYN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 FARMERS LN 500
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-6712
Mailing Address - Country:US
Mailing Address - Phone:707-569-3230
Mailing Address - Fax:707-523-0119
Practice Address - Street 1:1100 TRANCAS ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2908
Practice Address - Country:US
Practice Address - Phone:707-257-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA404009363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily