Provider Demographics
NPI:1528578531
Name:OSIBANJO, MOLLY FAYE (DC)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:FAYE
Last Name:OSIBANJO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MOLLY
Other - Middle Name:FAYE
Other - Last Name:DONNOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:851 W ELK AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2946
Mailing Address - Country:US
Mailing Address - Phone:423-542-2913
Mailing Address - Fax:
Practice Address - Street 1:851 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2946
Practice Address - Country:US
Practice Address - Phone:423-542-2913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor