Provider Demographics
NPI:1821628751
Name:WARNOCK, MOLLY E
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:E
Last Name:WARNOCK
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 1:16461 DOMESTIC AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-6008
Mailing Address - Country:US
Mailing Address - Phone:877-266-7768
Mailing Address - Fax:603-952-3900
Practice Address - Street 1:116 DEFENSE HWY STE 102
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7040
Practice Address - Country:US
Practice Address - Phone:888-820-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-20
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD363A00000X
FLPA9113778363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant