Provider Demographics
NPI:1013412386
Name:NISEN, MOLLIE BEA (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLIE
Middle Name:BEA
Last Name:NISEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:848-288-6935
Mailing Address - Fax:
Practice Address - Street 1:800 COOPER ST FL 4
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08102-1155
Practice Address - Country:US
Practice Address - Phone:856-342-3040
Practice Address - Fax:856-342-3049
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61055643207Q00000X
NJ25MA11921500207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104633Medicaid