Healthcare Provider Details

I. General information

NPI: 1932416948
Provider Name (Legal Business Name): JOHN M. MOLLINEAUX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 WINCHESTER AVE
ASHLAND KY
41101-7848
US

IV. Provider business mailing address

PO BOX 1595
ASHLAND KY
41105-1595
US

V. Phone/Fax

Practice location:
  • Phone: 606-408-2600
  • Fax: 606-408-2605
Mailing address:
  • Phone: 606-408-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number59306
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006897
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: