Provider Demographics
NPI:1235838715
Name:VASA, MOLLI MAE
Entity Type:Individual
Prefix:
First Name:MOLLI
Middle Name:MAE
Last Name:VASA
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 1:124 S 24TH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1226
Mailing Address - Country:US
Mailing Address - Phone:402-599-2056
Mailing Address - Fax:402-491-5075
Practice Address - Street 1:1420 E MILITARY AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-5300
Practice Address - Country:US
Practice Address - Phone:402-721-1774
Practice Address - Fax:402-721-9689
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist