Provider Demographics
NPI:1497888796
Name:CLEARY, MOLLY BRENDAN (RN, BSN)
Entity Type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:BRENDAN
Last Name:CLEARY
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 PARKLANE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-6015
Mailing Address - Country:US
Mailing Address - Phone:614-286-4353
Mailing Address - Fax:
Practice Address - Street 1:3175 PARKLANE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-6015
Practice Address - Country:US
Practice Address - Phone:614-286-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH203929163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2279985Medicaid