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General NPI Number Information
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NPI Number | 1407079429
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Entity Type | Individual
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Provider Name | MOLLY LYNN ANDERSON
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Gender | Female
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1 UNIVERSITY CIR WESTERN ILLINOIS UNIVERSITY
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City | MACOMB
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State | IL
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Zip | 61455-1367
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Country | US
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Telephone | 309-298-2135
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Fax |
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Provider Business Mailing Address
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Address Line | 630 S JOHNSON ST
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City | MACOMB
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State | IL
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Zip | 61455-2843
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Country | US
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Telephone | 217-316-6794
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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 |
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License Number State | IL
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