Provider Demographics
NPI:1962180075
Name:MATTICK, MOLLY (CNM)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MATTICK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:LALEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 22210
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94623-2210
Mailing Address - Country:US
Mailing Address - Phone:510-535-3926
Mailing Address - Fax:510-535-4189
Practice Address - Street 1:210 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2517
Practice Address - Country:US
Practice Address - Phone:707-645-7316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW236368176B00000X
OR10025320367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife