Healthcare Provider Details

I. General information

NPI: 1902598907
Provider Name (Legal Business Name): MOLLIE MAE ELLINGTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MOLLIE MAE WALKER RN

II. Dates (important events)

Enumeration Date: 05/26/2023
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

3625 KNOLL CREST TRL
BUFORD GA
30519-5074
US

V. Phone/Fax

Practice location:
  • Phone: 678-833-4123
  • Fax:
Mailing address:
  • Phone: 678-833-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN195588
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: