Healthcare Provider Details

I. General information

NPI: 1003598491
Provider Name (Legal Business Name): MOLLY ELIZABETH LIDDELL DNP RN AGCNS-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N 92ND ST
MILWAUKEE WI
53226-1202
US

IV. Provider business mailing address

7913 EAGLE ST
WAUWATOSA WI
53213-1150
US

V. Phone/Fax

Practice location:
  • Phone: 414-454-7154
  • Fax:
Mailing address:
  • Phone: 847-321-0791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number196383-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: