Healthcare Provider Details

I. General information

NPI: 1659069896
Provider Name (Legal Business Name): MOLLY JANE CHUDLEIGH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CONGRESS AVE STE 200
AUSTIN TX
78701-2432
US

IV. Provider business mailing address

300 S CONGRESS AVE STE 200
AUSTIN TX
78704-1221
US

V. Phone/Fax

Practice location:
  • Phone: 512-881-2515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1106617
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: