Healthcare Provider Details

I. General information

NPI: 1396512257
Provider Name (Legal Business Name): MOLLY GESSICA MAAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477-8803
US

IV. Provider business mailing address

5642 SW IDAHO ST
PORTLAND OR
97221-1625
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-8400
  • Fax: 541-222-8401
Mailing address:
  • Phone: 805-368-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number10034685
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95029029
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number10034685
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: