Healthcare Provider Details

I. General information

NPI: 1821322504
Provider Name (Legal Business Name): BRENDA LACEY MOLES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 S GRANITE ST
PRESCOTT AZ
86303-4710
US

IV. Provider business mailing address

620 LESTER DR
PRESCOTT AZ
86301-5371
US

V. Phone/Fax

Practice location:
  • Phone: 928-717-3276
  • Fax: 928-717-3275
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberAZ9203
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: