Provider Demographics
NPI:1134332604
Name:MOLLOY, MARY-ANN (RN, CNM, NP, MS)
Entity type:Individual
Prefix:MS
First Name:MARY-ANN
Middle Name:
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:RN, CNM, NP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:183-454-4170
Mailing Address - Fax:
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-471-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308584163W00000X
CA2384363L00000X
CA434367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ92073ZOtherMEDICARE GROUP ID
CAZZZ91892ZOtherMEDICARE GROUP ID
CAZZZ91891ZOtherMEDICARE GROUP ID
CAZZZ92069ZOtherMEDICARE GROUP ID
CAZZZ92073ZOtherMEDICARE GROUP ID