Healthcare Provider Details

I. General information

NPI: 1942531363
Provider Name (Legal Business Name): MOLLY ANNE RUSSELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MOLLY ANNE LESE

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE
MADISON WI
53792-0001
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-262-4402
  • Fax: 608-266-6075
Mailing address:
  • Phone: 608-829-5485
  • Fax: 608-833-0999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5065
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number5065-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: