Provider Demographics
NPI:1922793553
Name:MALMSTROM, MOLLY JANE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JANE
Last Name:MALMSTROM
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31183 180TH ST
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56586-9523
Mailing Address - Country:US
Mailing Address - Phone:218-405-0880
Mailing Address - Fax:
Practice Address - Street 1:111 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2741
Practice Address - Country:US
Practice Address - Phone:218-739-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10116363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics