Provider Demographics
NPI:1043220809
Name:HUDSON, MOLLIE T (NP)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:T
Last Name:HUDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:T
Other - Last Name:VENTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421-5100
Practice Address - Country:US
Practice Address - Phone:231-854-7235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704200905363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4951590Medicaid
MI4951590Medicaid
MI0N86600022Medicare PIN