Provider Demographics
NPI:1477104180
Name:TOLLEFSON, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:TOLLEFSON
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 1:16045 1ST AVE S FL 2
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1401
Mailing Address - Country:US
Mailing Address - Phone:206-965-4222
Mailing Address - Fax:360-697-2514
Practice Address - Street 1:16045 1ST AVE S FL 2
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148-1401
Practice Address - Country:US
Practice Address - Phone:206-965-4222
Practice Address - Fax:360-697-2514
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60964158367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2142785Medicaid