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General NPI Number Information
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NPI Number | 1003925819
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Entity Type | Individual
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Provider Name | MOLLY SUSAN PHILLIPP C.R.N.P.
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Gender | Female
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 05/10/2013
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Provider Practice Location Address
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Address Line | 2065 E 17TH ST SUITE D
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8042
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Country | US
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Telephone | 208-522-0747
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Fax | 208-522-9641
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Provider Business Mailing Address
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Address Line | 2065 E 17TH ST SUITE D
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8042
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Country | US
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Telephone | 208-522-0747
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Fax | 208-522-9641
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | NP320A
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363LX0001X
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Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
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License Number | NP320A
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License Number State | ID
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