Basic Information
| Provider Information | |||||||||
| NPI: | 1104395300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEARDEN | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1289 GI MADDOX PKWY | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307052069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069713366 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1289 GI MADDOX PKWY | ||||||||
| Address2: | |||||||||
| City: | CHATSWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307052069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7069713366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2018 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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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 | 164W00000X | LPN04532 | GA | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 164W0000X | 05 | GA | MEDICAID |