1154310902 NPI number — MOLLY ANNE MOORE-PULLIN A.N.P.

Table of content: MOLLY ANNE MOORE-PULLIN A.N.P. (NPI 1154310902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154310902 NPI number — MOLLY ANNE MOORE-PULLIN A.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE-PULLIN
Provider First Name:
MOLLY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
MOLLY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154310902
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86304-0880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-759-5874
Provider Business Mailing Address Fax Number:
928-458-2039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 AINSWORTH DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301-1623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-445-6025
Provider Business Practice Location Address Fax Number:
928-777-2423
Provider Enumeration Date:
10/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  RN049339 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Z214401 . This is a "MEDICARE INDIVIDUAL PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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