Healthcare Provider Details

I. General information

NPI: 1659753986
Provider Name (Legal Business Name): MOLLY BALDRIDGE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

IV. Provider business mailing address

115 PRIVATE ROAD 977
PEDRO OH
45659-8608
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-1386
  • Fax: 740-534-1497
Mailing address:
  • Phone: 740-534-1386
  • Fax: 740-534-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN.156205-M-IV
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.432108
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: