Healthcare Provider Details

I. General information

NPI: 1679007058
Provider Name (Legal Business Name): MOLLY CHRISTINE LINN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY CHRISTINE MANTHE

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 13TH AVE S
FARGO ND
58103-3602
US

IV. Provider business mailing address

306 ESTATE DR
AVON MN
56310-4539
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-3620
  • Fax:
Mailing address:
  • Phone: 320-761-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPT16515
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: