Healthcare Provider Details

I. General information

NPI: 1619480894
Provider Name (Legal Business Name): MOLLY JEAN HOVENDICK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTH DIVISION STREET
FORT LEWIS WA
98433
US

IV. Provider business mailing address

8569 HIGHWAY 789
LANDER WY
82520-9474
US

V. Phone/Fax

Practice location:
  • Phone: 307-349-0650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA161600256
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1008
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: