Provider Demographics
NPI:1154659373
Name:KIRKCONNELL, MOLLY REBECCA
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:REBECCA
Last Name:KIRKCONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5983
Practice Address - Street 1:3802 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OCCIDENTAL
Practice Address - State:CA
Practice Address - Zip Code:95465
Practice Address - Country:US
Practice Address - Phone:707-874-2444
Practice Address - Fax:707-874-2003
Is Sole Proprietor?:No
Enumeration Date:2009-11-28
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126516207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program