MEDICARE: MRS. MOLLY SUSAN PHILLIPP C.R.N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	NP320A	ID
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	NP320A	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003925819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MOLLY SUSAN PHILLIPP C.R.N.P.

Provider Business Mailing Address
First Line	:	2065 E 17TH ST
Second Line	:	SUITE D
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8042
Country	:	US
Telephone Number	:	208-522-0747
Fax Number	:	208-522-9641

Provider Business Practice Location Address
First Line	:	2065 E 17TH ST
Second Line	:	SUITE D
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-8042
Country	:	US
Telephone Number	:	208-522-0747
Fax Number	:	208-522-9641

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	05/10/2013

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