Healthcare Provider Details

I. General information

NPI: 1558931097
Provider Name (Legal Business Name): MOLLY WAMBACH APRN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 4TH ST S
FARGO ND
58103-1914
US

IV. Provider business mailing address

17061 50TH ST N
GEORGETOWN MN
56546-9432
US

V. Phone/Fax

Practice location:
  • Phone: 701-476-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR42008
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR42008
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: