Provider Demographics
NPI:1194794107
Name:MOL, VIRGINIA JEAN (FNP-C)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:JEAN
Last Name:MOL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 CHAMBERS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4571
Mailing Address - Country:US
Mailing Address - Phone:801-479-4105
Mailing Address - Fax:801-584-2590
Practice Address - Street 1:982 CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4571
Practice Address - Country:US
Practice Address - Phone:801-479-4105
Practice Address - Fax:801-584-2590
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT98-362692-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5598Medicaid
UTW23497Medicare UPIN
UT005511408Medicare ID - Type Unspecified