Provider Demographics
NPI:1003925819
Name:PHILLIPP, MOLLY SUSAN (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:SUSAN
Last Name:PHILLIPP
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 E 17TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8042
Mailing Address - Country:US
Mailing Address - Phone:208-522-0747
Mailing Address - Fax:208-522-9641
Practice Address - Street 1:2065 E 17TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8042
Practice Address - Country:US
Practice Address - Phone:208-522-0747
Practice Address - Fax:208-522-9641
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP320A363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002352900Medicaid
ID820296824OtherTAX ID NUMBER
ID002352900Medicaid