Basic Information
| Provider Information | |||||||||
| NPI: | 1811241706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049386144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077792628 | ||||||||
| FaxNumber: | 2077792303 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049386144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077792628 | ||||||||
| FaxNumber: | 2077792303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2012 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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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 | 163W00000X | RN57542 | ME | N | Nursing Service Providers | Registered Nurse | 363LF0000X | CNP121093 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.