Provider Demographics
NPI:1902041395
Name:MOLLE, STACEY MICHELLE (CNS FNP PMHNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:MOLLE
Suffix:
Gender:F
Credentials:CNS FNP PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7385 STATE ROUTE 3 # 1050
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8654
Mailing Address - Country:US
Mailing Address - Phone:614-664-8880
Mailing Address - Fax:
Practice Address - Street 1:200 EAST CAMPUSVIEW BLVD SUITE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235
Practice Address - Country:US
Practice Address - Phone:614-664-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-13
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH327159163W00000X
OHAPRN.CNP.020975363LF0000X
OH020975363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily