Healthcare Provider Details

I. General information

NPI: 1225197635
Provider Name (Legal Business Name): MOLLY AULTZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9775 SE SUNNYSIDE RD STE 200
CLACKAMAS OR
97015-5721
US

IV. Provider business mailing address

PO BOX 864
MOLALLA OR
97038-0864
US

V. Phone/Fax

Practice location:
  • Phone: 503-654-8417
  • Fax:
Mailing address:
  • Phone: 503-829-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: