Provider Demographics
NPI:1396060505
Name:FITZPATRICK, MOLLY EILEEN (LAC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:EILEEN
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 NE MADRONA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4066
Mailing Address - Country:US
Mailing Address - Phone:503-341-1372
Mailing Address - Fax:
Practice Address - Street 1:118 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2435
Practice Address - Country:US
Practice Address - Phone:503-288-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01261171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist