=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356221550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY FOX
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2025
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42 N W SILVER LAKE RD
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49685-8536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-943-5690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8660 N LONG LAKE RD
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49685-8249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-781-0998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704409349
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------