Healthcare Provider Details

I. General information

NPI: 1104057934
Provider Name (Legal Business Name): MOLLY ELIZABETH WHITLEDGE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 S MAIN ST
HENDERSON KY
42420-4364
US

IV. Provider business mailing address

1715 S MAIN ST
HENDERSON KY
42420-4364
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-5881
  • Fax: 612-794-3990
Mailing address:
  • Phone: 612-467-5881
  • Fax: 612-794-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number1101254
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1101254
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: