Healthcare Provider Details

I. General information

NPI: 1124703350
Provider Name (Legal Business Name): BRIANNA MONIQUE MOLINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 IDLEWOOD RD STE 1
TUCKER GA
30084-4827
US

IV. Provider business mailing address

6020 RIVER VIEW RD SE APT 9115
MABLETON GA
30126-3247
US

V. Phone/Fax

Practice location:
  • Phone: 678-205-2039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: