Provider Demographics
NPI:1457459349
Name:MOLLIS, STACEY NOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:NOEL
Last Name:MOLLIS
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Gender:F
Credentials:MD
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Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:MAIL CODE 11107E
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-9545
Mailing Address - Fax:651-254-1553
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MAIL CODE 11107E
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-9545
Practice Address - Fax:651-254-1553
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-12-01
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Provider Licenses
StateLicense IDTaxonomies
MN40579207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G70816Medicare UPIN