Provider Demographics
NPI:1477004653
Name:SIMONSON, MOLLIE
Entity Type:Individual
Prefix:MISS
First Name:MOLLIE
Middle Name:
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HIGHWAY 5 E
Mailing Address - Street 2:
Mailing Address - City:PLENTYWOOD
Mailing Address - State:MT
Mailing Address - Zip Code:59254-9618
Mailing Address - Country:US
Mailing Address - Phone:406-438-2726
Mailing Address - Fax:
Practice Address - Street 1:GONZAGA UNIVERSITY MSC 3838
Practice Address - Street 2:502 E BOONE AVE.
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99258-2500
Practice Address - Country:US
Practice Address - Phone:406-438-2726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-EMT-LIC-51614146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic