Provider Demographics
NPI:1467702274
Name:SPRAGUE, MOLLY LYN (MA60042872)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:LYN
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:MA60042872
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9803 NE 59TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662
Mailing Address - Country:US
Mailing Address - Phone:541-905-9112
Mailing Address - Fax:
Practice Address - Street 1:5501 NE 109TH CT STE L
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662
Practice Address - Country:US
Practice Address - Phone:541-905-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60042872172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist