Healthcare Provider Details

I. General information

NPI: 1780456384
Provider Name (Legal Business Name): HEATHER MOLITOR ACAGNP-BC, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

IV. Provider business mailing address

16601 N 40TH ST STE 204
PHOENIX AZ
85032-3356
US

V. Phone/Fax

Practice location:
  • Phone: 602-633-3721
  • Fax: 602-953-5466
Mailing address:
  • Phone: 602-633-3721
  • Fax: 602-953-5466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number295983
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: