Active NPI
Susan Michelle Moultrie, NURSE PRACTITIONER
- Family Nurse Practitioner
- Victorville, CA
National Provider Identifier
1629352901
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Nurse Practitioner
- License
- 12560
- Practice address
- 12830 Hesperia Rd Ste Cde
Victorville, CA 92395-7788 - Phone
- (760) 684-8999
- Fax
- (760) 684-8111
- NPI assigned
- Oct 4, 2011
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 12560 | CA | Primary |
Addresses
Primary practice location
12830 Hesperia Rd Ste Cde
Victorville, CA 92395-7788
Mailing address
4800 Citrus Ave
Apt 5104
Fontana, CA 92336
Phone (770) 712-3049
Other names 1
- Ms. Susan Michelle Moultrie
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12560 | CA | MD | Chiropractor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tobias Moeller-Bertram MD Corporation | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
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- NPI 1922440684
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1317686400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1730332800000",
"number": "1629352901",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4800 CITRUS AVE",
"address_2": "APT 5104",
"city": "FONTANA",
"state": "CA",
"postal_code": "92336",
"telephone_number": "770-712-3049"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12830 HESPERIA RD STE CDE",
"city": "VICTORVILLE",
"state": "CA",
"postal_code": "923957788",
"telephone_number": "760-684-8999",
"fax_number": "760-684-8111"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOULTRIE",
"first_name": "SUSAN",
"middle_name": "MICHELLE",
"name_prefix": "Ms.",
"credential": "NURSE PRACTITIONER",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2011-10-04",
"last_updated": "2024-10-31",
"certification_date": "2024-10-25",
"status": "A"
},
"taxonomies": [
{
"code": "363LF0000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner, Family",
"state": "CA",
"license": "12560",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"first_name": "SUSAN",
"last_name": "MOULTRIE",
"middle_name": "MICHELLE",
"prefix": "MS.",
"credential": "NURSE PRACTITIONER",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Victorville, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.