Provider Demographics
NPI:1992316905
Name:MCINNIS, MOLLY LOUISE (NP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:LOUISE
Last Name:MCINNIS
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 1:11096 LADUKE RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-9010
Mailing Address - Country:US
Mailing Address - Phone:989-798-2360
Mailing Address - Fax:
Practice Address - Street 1:1015 S WASHINGTON AVE FL 3
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2556
Practice Address - Country:US
Practice Address - Phone:989-907-8716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704314318363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner