Provider Demographics
NPI:1689953762
Name:MOLLOY, TARA JONES (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JONES
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-1543
Mailing Address - Country:US
Mailing Address - Phone:207-294-3111
Mailing Address - Fax:207-286-3907
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1543
Practice Address - Country:US
Practice Address - Phone:207-294-3111
Practice Address - Fax:207-286-3907
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP111062363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health