Healthcare Provider Details

I. General information

NPI: 1518482298
Provider Name (Legal Business Name): MOLLY LYNN MUDD RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

1 CHILDRENS PLACE OFFICE 8W23
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-477-9864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number2008022120
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20163161
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: