Provider Demographics
NPI:1316353733
Name:BROWN, MOLLY (FNP-BC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:
Practice Address - Street 1:84 MARGINAL WAY STE 1000
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2477
Practice Address - Country:US
Practice Address - Phone:207-774-4092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP151165363LF0000X
MARN2283233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3058Medicaid