Provider Demographics
NPI:1093201980
Name:MAYHUGH, MOLLY GRUBBS (FNP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:GRUBBS
Last Name:MAYHUGH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:MAYHUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOLLY GRUBBS
Mailing Address - Street 1:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:314 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-3702
Practice Address - Country:US
Practice Address - Phone:601-587-4304
Practice Address - Fax:601-587-4515
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902712363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01071599Medicaid