Provider Demographics
NPI:1225197635
Name:AULTZ, MOLLY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:
Last Name:AULTZ
Suffix:
Gender:F
Credentials:FNP
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 864
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-0864
Mailing Address - Country:US
Mailing Address - Phone:503-829-9293
Mailing Address - Fax:
Practice Address - Street 1:9775 SE SUNNYSIDE RD STE 200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5721
Practice Address - Country:US
Practice Address - Phone:503-654-8417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP73192Medicare UPIN