Provider Demographics
NPI:1073636205
Name:COLE, MOLLY DEIDRE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:DEIDRE
Last Name:COLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 N EDDY DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1018
Mailing Address - Country:US
Mailing Address - Phone:928-774-1430
Mailing Address - Fax:
Practice Address - Street 1:2300 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-4247
Practice Address - Country:US
Practice Address - Phone:928-773-4082
Practice Address - Fax:928-773-4086
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN137802163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ130600Medicaid
AZRN137802OtherRN LICENSE