Provider Demographics
NPI:1619673944
Name:MOLA, SELAMAWIT (FNP)
Entity Type:Individual
Prefix:
First Name:SELAMAWIT
Middle Name:
Last Name:MOLA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 E PONCE DE LEON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1839
Mailing Address - Country:US
Mailing Address - Phone:678-705-9685
Mailing Address - Fax:
Practice Address - Street 1:4600 E PONCE DE LEON AVE STE A
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-1839
Practice Address - Country:US
Practice Address - Phone:678-705-9685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN212894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily