Healthcare Provider Details

I. General information

NPI: 1326625500
Provider Name (Legal Business Name): MOLLY KOTZUBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 RICHARDSON TER
SOMERVILLE MA
02145-2536
US

IV. Provider business mailing address

7 RICHARDSON TER
SOMERVILLE MA
02145-2536
US

V. Phone/Fax

Practice location:
  • Phone: 857-654-7073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN2318358
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: