Provider Demographics
NPI:1285341370
Name:JUDGE, MOLLY MARIE (BSN, RN, CRNI, VA-BC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARIE
Last Name:JUDGE
Suffix:
Gender:F
Credentials:BSN, RN, CRNI, VA-BC
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:MARIE
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN, CRNI, VA-BC
Mailing Address - Street 1:4312 S FALCON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-9044
Mailing Address - Country:US
Mailing Address - Phone:812-361-3196
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-918-4155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28171852A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse