Healthcare Provider Details

I. General information

NPI: 1356842207
Provider Name (Legal Business Name): EMILY STAHL MOLLENKOPF NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 09/01/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 WINTER ST SE
SALEM OR
97301-3934
US

IV. Provider business mailing address

665 WINTER ST SE
SALEM OR
97301-3934
US

V. Phone/Fax

Practice location:
  • Phone: 503-561-5200
  • Fax:
Mailing address:
  • Phone: 949-357-9563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201403349RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60474139
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201908772NP-PP
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61005863
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201908772NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: