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General NPI Number Information
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NPI Number | 1124582853
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Entity Type | Individual
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Provider Name | MOLLY WEGNER
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Gender | Female
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Dates
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Enumeration Date | 01/28/2019
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Last Update Date | 01/28/2019
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Provider Practice Location Address
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Address Line | 2601 FORTUNE CIR E STE 105B
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City | INDIANAPOLIS
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State | IN
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Zip | 46241-5523
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Country | US
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Telephone | 317-995-2108
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Fax |
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Provider Business Mailing Address
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Address Line | 2357 STRINGTOWN PIKE
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City | CICERO
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State | IN
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Zip | 46034-9503
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Country | US
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Telephone | 317-445-5486
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36002535A
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License Number State | IN
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