Provider Demographics
NPI:1063835841
Name:MAHAN, MOLLY (LMP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MAHAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4402
Mailing Address - Country:US
Mailing Address - Phone:360-774-6184
Mailing Address - Fax:
Practice Address - Street 1:430 E LAURIDSEN BLVD STE 113
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7978
Practice Address - Country:US
Practice Address - Phone:360-457-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60437812172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker