Basic Information
| Provider Information | |||||||||
| NPI: | 1205282084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLTON | ||||||||
| FirstName: | MANDISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W MONROE ST STE 1200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606032420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 10553 SAINT CLAIR AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441081973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166827702 | ||||||||
| FaxNumber: | 2169206273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2016 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | COA.19066-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | COA.19066-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | COA.19066-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | COA.19066-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.