Provider Demographics
NPI:1376692236
Name:FORD, MOLLY JANE (ARNP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JANE
Last Name:FORD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-1812
Mailing Address - Country:US
Mailing Address - Phone:253-697-7400
Mailing Address - Fax:
Practice Address - Street 1:1518 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1812
Practice Address - Country:US
Practice Address - Phone:253-697-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007460163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8943399OtherSTATE CRIME VICTIMS
WA8943398OtherSTATE CRIME VICTIMS
WA0216687OtherSTATE L&I
WA9651548Medicaid
WA0216688OtherSTATE L&I
WAG8863357Medicare PIN
WA8943398OtherSTATE CRIME VICTIMS
WAG8863356Medicare PIN