Provider Demographics
NPI:1215919436
Name:MOLINA, BRENDA JOYCE (NP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:JOYCE
Last Name:MOLINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739
Mailing Address - Country:US
Mailing Address - Phone:541-536-8012
Mailing Address - Fax:541-536-9873
Practice Address - Street 1:16480 WILLIAM FOSS RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9486
Practice Address - Country:US
Practice Address - Phone:541-536-8012
Practice Address - Fax:541-536-9873
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363L00000X, 363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270016Medicaid
ORR132774Medicare PIN
P17170Medicare UPIN