Provider Demographics
NPI:1417949447
Name:MOLLNER, MARK A (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MOLLNER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 JEFFERSON AVE
Mailing Address - Street 2:MCDONALD ARMY HEALTH CENTER- FAMILY HEALTH CLINIC
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1602
Mailing Address - Country:US
Mailing Address - Phone:757-314-7613
Mailing Address - Fax:
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:MCDONALD ARMY HEALTH CENTER- FAMILY HEALTH CLINIC
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1602
Practice Address - Country:US
Practice Address - Phone:757-314-7613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24151992363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010115035Medicaid
VA010115035Medicaid
Q30770Medicare UPIN