Basic Information
| Provider Information | |||||||||
| NPI: | 1336286723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEADRICK | ||||||||
| FirstName: | MOLLIE | ||||||||
| MiddleName: | CHRISTENE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 OVERLAND PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRASELTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305171446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709671327 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1990 LAKESIDE PKWY STE 170 | ||||||||
| Address2: | |||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300845883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709381757 | ||||||||
| FaxNumber: | 7709381759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN134270 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.