Provider Demographics
NPI:1245800846
Name:LOUDERBACK, MOLLY RACHEL
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:RACHEL
Last Name:LOUDERBACK
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 1:110 SAINT BLAISE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-4594
Mailing Address - Country:US
Mailing Address - Phone:615-575-8106
Mailing Address - Fax:
Practice Address - Street 1:110 SAINT BLAISE RD STE 200
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-4594
Practice Address - Country:US
Practice Address - Phone:615-575-8106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant