Healthcare Provider Details

I. General information

NPI: 1588759641
Provider Name (Legal Business Name): MOLLY E MEHLBERG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD #480
GREEN BAY WI
54311
US

IV. Provider business mailing address

2064 E BARABOO CR
DEPERE WI
54115-6519
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8400
  • Fax:
Mailing address:
  • Phone: 920-338-9617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: