Provider Demographics
NPI:1346714243
Name:EAGLE, MOLLEY (CRNP)
Entity Type:Individual
Prefix:
First Name:MOLLEY
Middle Name:
Last Name:EAGLE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 US HIGHWAY 431
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-5908
Mailing Address - Country:US
Mailing Address - Phone:256-840-3437
Mailing Address - Fax:
Practice Address - Street 1:1925 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRE
Practice Address - State:AL
Practice Address - Zip Code:35960-2835
Practice Address - Country:US
Practice Address - Phone:256-677-4552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-146309163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
9236680348OtherDOT