Basic Information
| Provider Information | |||||||||
| NPI: | 1912961228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAPLETON | ||||||||
| FirstName: | MOLLIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2185250557 | ||||||||
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| Practice Location | |||||||||
| Address1: | 927 TRETTEL LANE | ||||||||
| Address2: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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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 | 207Q00000X | 41732 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 383818800 | 05 | MN | MEDICAID |