Healthcare Provider Details

I. General information

NPI: 1356104541
Provider Name (Legal Business Name): MOLLEY FAMILY HEALTHCARE & WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 07/01/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 SOUTH AVE UNIT 7
SECANE PA
19018-3541
US

IV. Provider business mailing address

649 SOUTH AVE UNIT 7
SECANE PA
19018-3541
US

V. Phone/Fax

Practice location:
  • Phone: 610-944-4290
  • Fax:
Mailing address:
  • Phone: 610-944-4290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. ANSU SIRYON MOLLEY
Title or Position: OWNER/CEO
Credential: FNP-BC
Phone: 610-944-4290