Provider Demographics
NPI:1992336382
Name:DIEBALL, MOLLY MARION
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARION
Last Name:DIEBALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W284N5240 JUNGBLUTH RD
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-9107
Mailing Address - Country:US
Mailing Address - Phone:262-370-3272
Mailing Address - Fax:
Practice Address - Street 1:2000 OBSERVATORY DR # 1037
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53706-1121
Practice Address - Country:US
Practice Address - Phone:608-262-3742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program