Healthcare Provider Details

I. General information

NPI: 1356158471
Provider Name (Legal Business Name): MOLLY O'DONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

9557 50TH ST S
MOORHEAD MN
56560-7705
US

V. Phone/Fax

Practice location:
  • Phone: 218-686-9121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberR34172
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: