Provider Demographics
NPI:1003598491
Name:LIDDELL, MOLLY ELIZABETH (DNP RN AGCNS-BC)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:DNP RN AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7913 EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1150
Mailing Address - Country:US
Mailing Address - Phone:847-321-0791
Mailing Address - Fax:
Practice Address - Street 1:900 N 92ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1202
Practice Address - Country:US
Practice Address - Phone:414-454-7154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI196383-30364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist